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EPIDEMIC CHOLERA? 



ITS 







f w^t 



AND THE BEST MEANS 

FOR ITS PREVENTION AND CURE, 

BEING A SYNOPSIS OF 

CHOLERA LITERATURE, EMBRACING, IN A CONDENSED FORM, THE 

VIEWS OF THE MOST EMINENT AND SCIENTIFIC AUTHORS 

OF EUROPE AND AMERICA, 

WITH A GLO SSAEY, 

Explaining all technical terms, and adapting it for the non-professional reader. 



If evert/ family in the Valley of ike Mississippi could possess a copy and 
study its contents, and act upon them, many lives would be spared. 



COMPILED BY 



G. HURT, M. 13., 



■ 



OF ST. LOUIS, MO. 



■ ♦ »•■#••■■ 






Saint Loins : 

P. M. PLNCKARD, NOS. 508 AND 510 PINE STREET. 

1867. 

7 



' 






v 



O THE 



CHIEF MAGISTKATES OF STATES 



A ST D THE 

Municipal Authorities of Towns and Cities 

IN THE VALLE? OP THE MISSISSIPPI 



THIS LITTLE VOLUME IS RESPECTFULLY DEDICATEE^ 



BY THE COMPILE 



STEREOTYPED BY 

T. N . JOHNSON 



PREPACK, 



The public have long felt a want of information in regard to the causes* 
'nature and treatment of this terrible pestilence, which they have not had it 
in their power to gratify; and they seem to have settled down upon the con- 
clusion that medical men are either selfish or ignorant, and incapable of 
replying satisfactorily to their oft-repeated inquiries. 

The following pages aire intended to suppW, in a -concise form, at least a 
portion of the information "so urgently demanded, and will, at the same time* 
we trust, exonerate the medical profession from the charge, either of selfish- 
ness or indifference. It will be seen, from a perusal of these extracts, that the 
obstacles in the way of a satisfactory solution Of the problem are of such a 
nature as not to be overcome in a day ; and though we can not, as yet, boast of 
a complete triumph, scientific men have, in the progress of their investiga- 
tions, developed facts, which, when understood and acted upon, can scarcely 
fail to abate the virulence of the malady and lesson its fatality. 

As the Valley of the Mississippi, from the alluvial nature of its soil, the 
luxuriance of its vegetation, its topography and the sluggishness of many of 
its streams, is particularly liable to the visitation and spread of epidemic dis- 
eases, it is the dut}% not only of medical men, but of the people generally, to 
acquaint themselves, as far as practicable, with their causes and usual modes 
of propagation, and adopt the most rational and practical methods for their 
prevention or mitigation ; and as cholera will probably renew its ravages 
amongst us during the present season, no time should be lost in preparing to 
meet it. It is an old adage, that " an ounce of prevention is better than a 
pound of cure," and there is no disease in which its truth is more fully veri- 
fied than m cholera ; and in the present state of our knowledge, it is far 
better and wiser to direct our efforts to the adoption of such measures of 
public hygiene as will be calculated to promote the general health of the 



IT 

community, and in doing so, there is hope, at least, of abating the malig-*- 
nancy of the disease, if not of preventing it entirely. 

3Phe practicing physician can not, by unassisted efforts, afford immunity to- 
entire communities from the ravages of epidemic diseases. All that can be 
expected of him is, that he will co-operate freely in measures for the promo- 
tion of the general health. And it is for this purpose that this brief synopsis 
of the views of the most enlightened minds of the profession has been com- 
piled, and is respectfully commended to the attentive perusal of the intelli- 
gent reader ; and those who read it can scarcely fail to perceive that their 
immunity will depend much upon their own united efforts in the adoption 
and enforcement of proper sanitary measures. Some "discrepancy will he 
observed in the opinions of the authors quoted in regard to the pathology of 
this disease, but in the importance and the necessity of hygiene and disinfec- 
tion there is sufficient harmony to direct public attention to them as measures 
of the first importance, and their general adoption offers not only a fair pros- 
pect of immunity from Cholera, but an abatement of all other epidemic or 
zymotic diseases, a reduction of the ratio of mortality, and a corresponding; 
elevation of the standard of health in the community. 



EPIDEMIC €HOLEEA: 

ITS 

CAUSES, PATHOLOGY, &c. 



ON PTJELIO HEALTH. 

[Extract from an Address by W. Farr, M. D., F. K. S., before the Tenth Annual 

Meeting of the National Association for the Promotion of Social Science. 

Manchester, 1866 ] 

" Life can be saved by studying the causes of its destruction 
— injuries and diseases. Lightning had no sooner been identi- 
fied with electricity, than Franklin invented the lightning con- 
ductor. With his knowledge of flame and gasses Davy invented 
the safety-lamp to save men from the terrible effects of explo- 
sions. The same object is secured now effectually by the" im- 
proved ventilation of mines. Eire-escapes and fire-guards save 
hundreds of- lives from the flames. Life-boats rescue mariners 
from the waves Chemistry finds antidotes for poisons. Sur- 
gery, armed with Harvey's discovery, ties bleeding arteries. 
From Jenner, medicine has learnt by vaccination to prevent 
small-pox. And this brings us to the elass,-of zymotic disease, 
over which new power has been acquired recently by the dis- 
covery in England of the laws of its propagation. 

A surgeon dips a lancet into the pustule of a small-pox 
patient 5 on its point is a drop of transparent lymph; and that 
lymph, mixed in the blood of a child that has not before had 
the disease, reproduces the lymph in new pustules, which will 
regain propagate the disease among other children. The matter 
its volatile, and other children brought into the same atmosphere 
;&ve said to <eatch small-pox. If the lymph is derived from & 



cow-pox pustule, it reproduces cow-pox. In Targe lying-m-nos^ 
pitals it has been found by repeated experience that child-bed 
fever, or what I call metria, is generated: one woman falls ill,. 
other women take it; every fresh, patient that enters dies.; and 
if the hospital nurse attends a lady out of doors, that lady will 
probably die of child-bed fever. Erysipelas, pyaemia and gan- 
grene are generated when you crowd wounded soldiers in mili-. 
tary hospitals; and the specific matter of each of these diseases. 
produce the same specific diseases in other soldiers. 

Typhus has been generated in jails^ and has infected the 
judges in courts as it infects physicians in fever hospitals. Here 
is a large number of diseases which we know how to produce;; 
and a second group, equally numerous, we know how to propa- 
gate — such as measles, scarlatina, whooping-cough and small- 
pox. .In the statistical nosology I classed all diseases of this 
kind together, under the head of zymotic diseases; and in the 
analysis of morbid phenomena, gave names to the different spe- 
cies of matter generated in each malady Thus,, selecting a few,, 
the matter of small-pox (variola) is called varioline; of cow-pox,. 
vaccinine ;. of erysipelas, erysipeline ;• of scarlatina, searlatinine ; 
of syphilis, syphihne ; of typhus, typhine ; of dysentery, enterine ; 
of cholera, cholerine. These matters introduced into the blood 
directly by inoculation, or by air, or by water, only induce their 
transformations in a certain number of the persons exposed to 
their action. They vary from day to day in strength. Cases of 
small-pox, for instance, occur every week in London; few chil- 
dren die of small-pox for weeks together, when suddenly the 
varioline becomes active, is. multiplied with redoubled velocity, 
destroys large numbers, and after a time again becomes quies- 
cent. All zymotic diseases follow this law, and are hence called 
epidemics, endemics, plagues, which, as their cause is not evi r 
dent, have often been referred to supernatural agency. In their 
eourse they are generally influenced by atmospheric vicissitudes r 
but the zymotic stuff probably acquires its extreme diffusiveness 
in some wretched families under hygienic conditions that favor 
its creation. Ablatio cholera thus, originated, in the delta of tb&: 



Ganges, in spots where the huts are on the mounds, surrounded 
with pits, which are the receptacles of dejections and of the stag- 
nant water the natives drink. Jameson says, " Bad water, no 
doubt, sometimes immediately induces the disorder/ 7 In India 
they had advanced scarcely any further in the etiology. The 
English reports on the epidemic of 1832 and the elaborate of- 
ficial French report discussed all the conditions except one likely 
:to influence its course, and their results were purely negative. 
They stated, but did not solve, the problem of the disease. The 
English system of registration was established in 1837, and in the 
epidemic of 1848-49, the age, profession, date of death, and the 
place of death of each person by cholera was published by the 
Registrar-General in the London weekly tables of mortality. 
These tables were freely distributed among men of science, who 
had thus an opportunity of studying the facts. London pre- 
sents a favorable field for the analysis of epidemics. It has a 
vast population, spread over a large area at different elevations, 
arising from ground below the Thames level to Hampstead and 
Norwood. The population exists in every degree of density, in 
every degree of poverty and wealth. It was supplied in 1849 by 
eight companies with unfiltered water, some of it drawn from 
springs, the rest from different points of the Thames and its 
tributary, the Lea. At that time the sewers of London poured 
their contents into the Thames at different parts of its course, 
so that the waters o-f the companies differed very much, in im- 
purity. At Hungerford Bridge it was charged with soil, and 
higher up the tidal stream the water was comparatively pure. 
It was immediately found, on examining the returns, that 
cholera was much more fatal on the south side of the Thames 
than on the north; and at th« close of the epidemic, calculation 
showed that the mortality had been at the rate of 41 on the 
north, and 120 in 10, (K0 on the south banks. The two popula- 
tions differed in many respects, and further analysis was neces- 
sary. Ihe population in 38 districts, each a large city in mag- 
nitude, was variously grouped according to (1) wealth deter- 
mined from rated .value, (2) density, (3) elevation, and (4) water- 



8 

supply. It was shown that density and wealth in their different 
degrees had an influence on the mortality of the epidemic; but 
that the effects of these influences were completely overwhelmed 
by the influence of water and of the elevation of the soil. Thus, 
the six districts supplied with the least impure water lost, in 
every 10,000, 15 by cholera; the fifteen districts getting still 
more impure water, lost 48; those getting the water from the 
parts of the Thames saturated with sewerage, lost 128. The air 
and the water of wells, and the water containing impurities in 
suspension, running along tubes underground from the river up 
the sides of hights, contain different amounts of such matter in 
suspension at different elevations ; and it was found that the 
mortality ranged from 174 deaths by cholera in 10,000 people 
on a level with the Thames, to 9-9 among, those living on ground 
ten feet higher, and thus the mortality fell to 53,. to 36, to 27, to 
22, to 20, to 8 ; as you ascend, 30, 50, 70, 90, 100, 3M) feet. above 
Trinity high- water mark. In the epidemic of 1853-4 and in the 
epidemic of 1866, the same laws prevailed. 

That was all that could be rigorously determined in 1848-9, 
and the experiment was incomplete, as the drainage of the 
ground and other conditions in which the people of South 
London lived differed 1 in many respects from the corresponding 
conditions on the north side of the Thames. South London is 
supplied chiefly by two companies. In the interval between 
1849 and 1855, one company supplying South London was 
driven higher up the Thames, and got above Teddington Lock, 
water uncontaminated with London Sewerage, whi'e the other 
company still drew its water in 185 i from the impure stream 
below. Here was an experiment on a grand scale. Asiatic 
cholera was epidemic once more, and retained its full power of 
destruction in the districts still supplied with impure water; but 
it was immediately discovered in the returns of the weekly 
tables that the mortality in the districts supplied with the better 
water was diminished. The difference was striking in houses of 
the same street supplied by the two companies, and it was ob, 
served every week in every district. After the: epidemic was- 



9 

over, the two companies furnished lists of all the houses which 
they supplied, and when the deaths by cholera in these two 
classes of houses, both in 1849 and 1854, were taken out at the 
General Register office and tabulated, the result satisfied the 
Committee for scientific inquiries of the Board of Health that 
the diminished mortality was due to the change in the quality 
of the water, 

Thi3 reasoning involves no theory. The result is arrived at 
by induction drawn from a vast number of instances all concur- 
ring. But I am bound to notice here an important theory which 
was advanced in 1819 by Dr. Snow, a London physician, who 
died young, but whose name will not perish. This, in a lew 
words, is Snow's theory: The rice-water discharges are to 
cholera what the lymph (varioline) is to smallpox ; the matter 
is generated in the body, it is multiplied in the intestines, and 
diffused by direct handling or by water, and, I should add, by 
air, in certain states carrying it suspended as dust — cholera-dust. 

Dr. Baly, in his admirable but cautious report to the College 
of Physicians, decided against the theory, and, in fact, the evi- 
dence then in its favor was not conclusive, But Dr. Snow 
persevered; he collected instances of the communication of the 
disease through pumps, wells and rivers ; and, in 1854, inquired 
at every house of certain districts where deaths from cholera 
occurred in Southwark. Thus he collected many new confirm- 
atory facts. Some links had been left incomplete in the verifi- 
cation of the" law that cholera matter (cholerine) is diffusible 
through water; these have been supplied in the present year, 
partly by what I can not but consider a deplorable accident. 

South London, it will be recollected, was still supplied with 
impure water in 1854 by orte company (the Southwark), and it 
suffered severely in the epidemic of that year. In the field oi 
the other company (Lambeth) the mortality was much reduced, 
but was not inconsiderable. In 1866 South London was sup- 
plied with water by the two companies from the purer sources; 
the shallow wells were dried by the metropolitan drainage, and 
the deaths by cholera in all the districts, holding 873,548 people* 



10 

were not so numerous as the deaths had been in 1854 in a single 
district. Thus you have these sequences: in the Lambeth field, 
impure water, 1849, cholera terribly fatal — pure water, 1854, 
cholera much less fatal; in the South wark field, impure water in 
1849 and in 1854, cholera terribly fatal in both years ; in 1866, 
both fields with pipes interlaced, in South London, supplied with 
the purer water — mortality from cholera comparatively slight, 
but sufficient to remind us that the water is not yet perfectly 
pure. 

Cholera had been epidemic in the continental cities since 
1865, but London rested secure, expecting to escape with "com- 
parative impunity, when lo I in July, the weekly deaths by 
cholera sprang up from 6 to 14, to 32, to 346, to 904, to 1,053, 
with an unexampled velocity, and threatened to renew all the 
horrors of the former plagues. The weekly returns showed 
that multitudes of men, women and children, spread over an 
area of about ten squire miles, were indiscriminately struck 
down by diarrhoea or cholera. 

In East London 3,613 people perished in six weeks. The 
great destruction of life occurred in every district, nearly every 
sub-district, supplied from the Old Ford reservoirs of one of the 
eight London companies, and to the same extent no where else. 
These reservoirs are close to the Lea, which is a tidal river, 
polluted with the sewerage of West Ham and of East London. 
In Manchester the water is immediately under the control of 
the Town Council, and you can know all about the supply; but 
in London that is not the case, as the water is supplied by 
private companies on strictly commercial principles. The direc- 
tors are not bound to tell us precisely what their servants do, 
and they have not done so; but circumstantial evidence irresist- 
ibly shows that polluted water was distributed over all the area 
of extraordinary mortality during a certain number of days, 
with the same result as in previous epidemic years. The source 
of mischief was no sooner pointed out than the plague began 
rapidly to decline; it appeared to be under control, and the 



■^■H 



11 

mortality by cholera in East London is now as low as it is in 
the rest of the metropolis. 

When zymotic matter or any impurity is thrown daily into 
the mains, pipes, butts, houses, and, I may say, bodies of a popu- 
lation,^ is irregularly distributed, and requires many successive- 
daily changes to eliminate it; thus, when impure water is sup-, 
plied for three days only, it may take thirty days to eliminate 
it. This may bo demonstrated mathematically, and be illus- 
trated by experiment. 

I may add that, although the distress from the loss of thou- 
sands of children and parents in an epidemic is never wiped 
away, }^et in East London it has been mitigated; the people 
behaved with courage and patience; they helped each other in 
danger, and they wore helped by enlightened English charity. 
The Queen herself came to their lelief; Mrs. Gladstone, Miss 
Marsh, Miss Sellon and Miss Louisa Twining, treading in the 
steps of Miss Nightingale, administered relief to the sufferers j. 
the Bishops of London and the Lord Mayor upheld the honor of 
their high office by indefatigable services. The medical men, 
and, it is right to add, the clergy, nobly did their duty; the 
local authorities, to a greater extent than they ever did before,, 
carried out the judicious recommendations of the Privy Council. 
House to house visitation was in many cases in use for a time. 

By these means, by the exertions of the engineers of the com- 
panies, and by the earl} 7, discovery of the source of the terrific 
mortality in East London, the plague has been stayed; we now 
know how Asiatic cholera can be subdued. In London twenty 
thousand lives have been saved. This is an achievement of the 
science of health which reflects some glory on England, and of 
which all the world will enjoy the advantage. It is due to 
many years of labor — to the labor of Jameson, Scott, Orton, 
Balfour, Martin, Parkes, in India ; to Sutherland, Smith, Ba!y> 
Gull, Simon, and especially to Snow, in England; to the English 
registration of deaths, which enabled us to demonstrate by 
several experiments in the largest city of the world; the fatal 
effects of water tainted by imparities. 



12 

How did it happen that the disastrous effects of the diffusion 
of this matter through water were not discovered in Paris or 
elsewhere ? For this simple reason, that when the observer has 
under his eyes a population all supplied with impure water, he 
can not logically refer the effect to the specific cause. For this 
happens in cholera, as in all zymotic diseases, only one individ- 
ual in a given number is susceptible; for the sake of illustration 
say one in four. Only one in the number susceptible (say one 
in five) by chance comes in contact with the stuff; and only one 
vessel of water in a given number (say six) contains a dose 
strong enough to induce Asiatic cholera, as it is called. Then, 
by the doctrine ■ of chances, only one in one hundred and 
twenty (that is, 1-5x1-6X1-4) will be attacked, and about one 
in two hundred and forty will die of the disease. Great num- 
bers will be attacked by diarrhoea and milder forms, but one 
hundred and nineteen will not be attacked by cholera while one 
is attacked. Here are one hundred and nineteen instances in 
favor of, and one against the water. 

In the worst district of the East London field 1£3 in 10,000 
people died of cholera. Say that 386 were attacked, then 9,614 
were not attacked, and the health officer might reason thus : 
9,611 persons in this district exposed to the cause — water — were 
not attacked, therefore the disease was not caused by the water; 
and of the 386 attacked some drank no water, the fact being 
that they were tainted in other ways. This logical difficulty is 
the origin of the greater part of the disputes on contagion. We 
overcome it by comparing the mortality of cholera in all the 
East London districts, the Lambeth districts, the Southwark 
districts, with the mortality of all the districts — many of them 
similarly situated as to condition — supplied with water from 
other sources. As the difference is uniformly enormous in 
successive trials at distant dates, the conclusion is irresistible. 

In Manchester the people have, with great credit to their 
intelligence, secured a supply of pure water; in faet the 83'stems 
«f Manchester and of Glasgow are models to other cities. But 
Manchester retains the excreta of the sick from all zymotic 



IS 

diseases, with o^her impurities, close to the dwellings and under 
the faces of the people. By comparing the mortality of the city 
so organized with that of London when the metropolitan drain- 
age is in full operation, and with that % of other cities where such 
matters are now carried off by water, you will be able to 
anaij T ze the effect of your system of arteries without veins, and 
I suspect that it will be decisively condemned by the result. 
The effect of a multitude of other causes on health, such as 
overcrowding, un cleanliness and drunkenness, can be tested by 
the same methods. 

To render our investigation of- causes affecting public health 
complete, there should be a public registration of every form of 
sickness and infirmity, as well as tests of strength by the 
quantity of work performed, either mental or muscular. The 
conscription and recruiting examinations are the only tests now 
in use. 

The sanitary society in Manchester has commenced some 
work of this kind, and will, I hope, persevere. In the diffusion 
of sound, practical, sanitary information, the Ladies' Sanitary 
Association in London has already rendered services which we 
are bound to recognize. The Universities of England will, I 
hope, teach, as the Continental Universities do, the doctrines of 
public health, and by recognizing the doctrines in granting 
degrees, as suggested by Mr. Rumsey, they will promote the 
health of their country. Manchester and all our cities will, like 
Liverpool, Glasgow, and some districts of London, have accom- 
plished officers, educated in the end specially for the purpose, 
keeping incessant watch over their health, like tutelary geniuses, 
and doing good not only to the inhabitants, but to mankind. 

For what good has been done hitherto by hygiene, however 
striking in building up healthy generations, is nothing com- 
pared with what remains for it to accomplish in times to come. 

Let there be a small ratio of improvement among the millions 
born every year in the successive generations of our own race — - 
in the races of Europe — and under that law of geometrical pro- 
gression even with which the world has been sometimes terrified 



Unreasonably, mankind will attain a degree of excellence of 
which we have no conception. Healthier, happier men may 
become, as by miracle only a little lower than the angels in thG 
golden age> the paradise -of the future* 



*THl INFLtt&NCl Otf IMPURE WAT^R ON" 'tHE DEVELOPMENT 
Otf EPIDEMIC CHOLERA. 

BY Dr. Norman Chevers. 
[Indian Annals of Medical Science, AugUst, 1866]. 

Dr, ISTorman Chevers supplies an instructive illustration of the 
influence of impure water in the development of cholera, from 
the presumed chief focus of the disease, the delta of the Ganges. 
in a valuable article, on the "Means of Preserving the Health 
of Seamen," especially those frequenting Calcutta and the other 
Indian ports, h& states that one of the leading Calcutta physi- 
cians has recently examined the whole line of river bank along 
Which the shipping are moored. This gentleman commences 
his report by saying that his object is to draw attention to the 
causes which, at certain seasons of the year, are actively engaged 
in destroying those who are condemned to live on this ''polluted 
river/' which he, not too emphatically, designates as the "Mael^ 
Strom of Death." 

u His metaphor," writes Dr. Chevers, "points to that stern 
reality, the poison of, cholera, which, discharged at various 
points, in the shape of sewerage, upon the river bank and in the 
centre of the stream, pollutes the water and the air; and, added 
to other malignant influences, common to all rivers in malarious 
"countries at remote distances from the sea, converts a haven of 
refuge into a port of danger. He shows that, the night soil of 
Calcutta is deposited in the Hooghly, at midstream, at a point 
1 opposite the night-soil ghat, at the rate of 180 tons a day j that, 
during certain months of the year, the river water at Cossipore, 
two miles up the stream) is, owing to the large quantity of sew- 
erage matter which it holds in solution, quite unfit for human 



it 

Consumption; arid that, under the influence of an unusually higfl 
tide, the water at Barrackpore even, thirteen miles further upy 
becomes contaminated} and yet the river water is drunk by sail- 
ors in ships moored at various points between this reservoir of 
night-soil and the sea. Immediately below the night-soil ghat 
are a large food-market and a landing place for boats, to which 
are brought rice* mangoes, etc.', for the consumption of the town. 

'< Again, near Ohampatola Ghat may be seen a large quantity 
of stable manure and other refuse, and near Prosona Coomar 
Tagore's Ghat a still larger quantity, deposited with a view of 
filling up hollows and gaps in the bank. ? Conceive/ Dr. — — » 
exclaims, ' the loss to agriculture, the gain to the poisoned at- 
mosphere of the harbor !' Next, the Burning Ghats. Admit- 
ting that the process of cremation pollutes a small area only,, 
and that those who live within that area have become habituated 
to, and so remain unaffected by it [[ once had the misfortune 
to live within that area. I became ' habituated * to it, but never" 
ceased to be ' affected ' by it. A most horrible and diabolical 
smoke, thick and heavy, plentifully throwing down a black 
greasy snou), and with an odor in comparison with which the 
fumes of burning hospital blankets are an Arabian perfume] 
still a pernicious influence must extend to tho ships lying to lee- 
Ward, when the wind blows over them from these centres of in- 
cineration of human flesh. 

" Then the sewers. Of these Dr -* counted twenty-two be-' 

tween the ghat opposite the Chitpore Dispensary and Hastings 
Bridge, a distance of four miles. Between tnese points are the 
principal moorings of the harbor. There are others lower downy 
such as the 'Kidderpore' and 'P. M 0/ moorings, etc. 

" The mouth of each sewer opens directly upon the commence- 
ment of the soft mttddy bank, on the irregular surface of which 
much of the contents is retained ; and in February, March, April, 
May and June, the poison of cholera, from this source, is in ac- 
tive operation. It is worthy of note that a sewer empties itself 
close to each of the principal bathing ghats. As if the sacred 
Stream was not already poisoned enough by the daily Augean 



16 

deposit of night- soil, the bathers are furnished with a special 
fountain for themselves. Some of the sewers have acquired 
a great notoriety, and it has long been known that the ships 
moored near them have sent more cases of cholera to the hos- 
pital than others which have been moored elsewhere. ^ It is 
idle/ Dr. exclaims, Ho talk of unripe fruits and bad lemon- 
ade ; of Jack's imprudence in exposing himself to the sun j of his 
drunken habits, etc., and then to add — no wonder he gets an at- 
tack of cholera ! Doubtless, all these have their influence in 
predisposing him to the disease, or in evoking it 3 but the Jons 
et origo remains, and we must not continue to shut our eyes to 
the fact/ He then cites Mr. Hugh Macpherson's observations, 
and goes on to show that, of 392 cases of cholera which have 
been admitted into the Medical College Hospital during the 
three years ending in 1865, 189, almost half, have come from the 
ships in the harbor. Of the sailors who live on board their 
ships, three per cent, annually are taken to the hospitals ', 
whilst, of those who live in Lai Bazaar and its purlieus, twenty 
per cent, are sent there. Of the admis3ions from the river, two- 
thirds are from cholera, whilst of those from the shore only a 
tenth part are attributable to that disease! Of the 189 cases 
sent fiom the river to the Medical College Hospital, the Esplan- 
ade moorings have supplied thirty-four per cent.., the remaining 
sixty-six per cent, being brought from twenty-five other moor- 
ings. During the same period 303 cases of cholera have been 
received into the General Hospital from ships. Of these fifteen 
per cent, have come from the l Esplanade/ and seventeen per 
cent, from the ' Cooly Bazaar ' moorings, whilst the remaining 
sixty -eight have been distributed over twenty-six other moorings. 
Yerj- few cases are taken to the Medical College Hospital from 
1 Cooly Bazaar ' moorings, owing to the great distance. The 
cases which occur in them are sent to the General Hospital. 
Cases from the ' Esplanade ? moorings, on the other hand, are 
principally taken to the Medical College Hospital, it being the 
nearest of the two. It thus appears that the 'Esplanade' and 
' Cooly Bazaar ' moorings are amongst the favorite haunts of 



17 

cholera. It is urged that crowding may partly account for these 
results But we find that the l Prinsep's Ghat' moorings, where, 

in Dr. 's recent excursion, there was a greater crowd of 

ships than elsewhere, have, during the period under review, sent 
onlj r nine cases of cholera to the General and Medical College 
Hospitals, the ' Esplanade ' moorings have sent ninety-four, and 
the ' Cooly Bazaar ' sixty one. The former of these two is now 
the most prolific in cholera poison; the latter, though still preg- 
nant with it, has materially improved in this respect during 
the past few years. The comparative immunity of the ' Prin- 
cep's Ghat ' moorings from cholera maybe due (and although 

Dr. is not prepared to state it as a fact, he believes that it 

is so) to the sewer which opens into the river opposite to these 
moorings, conveying only surface drainage. He believes that 
conservancy laws have been brought to bear upon the ' Cooly 
Bazaar ' locality generally; and that great improvements have 
been made in the river bank at this point. The result is encour- 
aging, and should lead to further endeavor." 



ON THE MODE OF PROPAGATION OF CHOLERA. 

By Mr. John Simon, F. R. S., Medical Officer of the Privy Council. 

[Official Memorandum, July, 1866]. 

The following observations on the mode of propagation of 
cholera are from the official memorandum of the Medical Officer 
of the Privy Council, on the precautions to be taken against the 
epidemic under the Eegulations issued by the Lords of the 
Council, and otherwise : 

" That such precautions (never unimportant where human 
health is to be preserved) are supremely important when the 
spread of cholera is to be prevented, is a truth which will best- 
be understood when the manner in which cholera spreads is 
considered. Happily for mankind, cholera is so little conta- 
gious, in the sense in which small-pox and typhus are com- 
monly called contagious, that, if proper precautions are taken 



18 

where it is present, there is scarcely any risk that the diseas© 
will spread to persons who nurse and otherwise closely attend 
upon the sick. But cholera has a certain peculiar contagious- 
ness of its own, now to be explained, which, where sanitary 
circumstances are bad, can operate with terrible force, and at 
considerable distances from the sick. It appears to be charac- 
teristic of cholera — not only of the disease in its developed and 
alarming form, but equally of the slightest diarrhoea which the 
epidemic influence can produce — that all matters which the pa- 
tient discharges from his stomach and bowels are infective ; that 
the patient's power of infecting other persons is represented 
almost or quite exclusively by those discharges ; that they, how- 
ever, are comparatively non-infective at the moment when they 
are discharged, but afterwards, while undergoing decomposition, 
acquire their maximum of infective power ; that, if they be 
cast away without previous disinfection, they impart their own 
infective quality to the excremental matters with which they 
mingle, in the filth-sodden earth or in depositaries or conduits 
of tilth, and to the effluvia which those excremental matters 
evolve; that if the infective material, by leakage or soakage 
from drains or cesspools, or otherwise, gets access, even in the 
smallest quantity, directly or through porus soils, to wells or 
other sources of drinking-water, it can infect, in the most dan- 
gerous manner, very large volumes of the water; that the infec- 
tive influence of choleraic discharges attaches to whatever bed- 
ding, clothing, towels, and like things have been imbued with 
them, and renders these things, if not disinfected, ca'pable (as 
the cholera patient himself would be capable, under the same 
conditions,) of spreading the disease in places whither they are 
sent for washing or other purposes; that, in the above described 
way, even a single case of disease, perhaps of the slightest de- 
gree, and, perhaps, quite unsuspected in the neighborhood, may, 
if local circumstances co-operate, exert a terribly infective power 
on considerable masses of population. ' If local circumstances 
€0-operate/ however, is the stated condition for that possibility ; 
and it will be observed that the essence of the sani ary precau- 



19 

lions which have been recommended to nuisance authorities and 
others is, to annihilate those 'local circumstances/ The chol- 
eraic infection does not seem able largely to infect any popula- 
tion unless a filthy state of things be presupposed. It is pre- 
supposed that the atmosphere or the drinking water of the 
population is impure with the most loathsome impurities — that 
the infective material has had opportunities of action which de- 
cent cleanliness would not have afforded it — that, in inefficient 
drains or cesspools, or other like depositories, it has had time to 
■develop its own infective power, and to render other stagnating 
filth equally infective with itself^ and that from such foci of in- 
fection the disgusting leaven of the disease has spread, in air or 
water, to be breathed or swallowed by the population. In this 
view of the ease, it will be understood that works of sewerage, 
-house-draining and water-supply, properly executed and properly 
used, give to town populations an almost absolute security that 
cholera, if introduced among them, can have no means of spread- 
ing its infection. And equally it will be understood ihat, in the 
absence of those permanent safeguards, no approach to such se- 
curity can be got without incessant cleansings and -disinfections, 
t)r without extreme vigilance against every possible contamina- 
tion of drinking water. " 



NATUBB OF THE SUPPOSED CHOLEKAIC POISON. 
Dr. Julius Althaus observes -; " Some experiments which were 
lately made by Professor Horn, of Munich, seem to bring us a 
step in advance of our efforts to determine the nature of the 
choleraic poison. He connected the prime conductor of "an elec- 
trical machine, the plate of which had a diameter of not less 
than three feet, with one end of a copper-wire, the other end of 
which was put into a tumblerful of water. The machine being 
put into action, this water was promptly ozonized. On the 
other hand, it was found that if one end of the wire was con- 
nected with the cushions instead of with the plate, so as to re- 



ceive negative electricity, the water was impregnated with m 
cyanide. A person who frequently smelt at this water, and 
drank some of it, was seized with symptoms of severe cholerine, 
which were, however, quickly arrested by drinking some of the- 
ozonized water. In presence of these experiments it seems to 1 
me very important that the drinking-water of our present chol- 
era fields should be examined for cyanides, more especially a& 
there is considerable analogy between the symptoms of cholera 
and those of poisoning by cyanides. Many facts which have 
been brought to light by previous experience might be satisfac- 
torily explained by assuming the choleraic poison to be a cyan- 
ide. Thus we know that water which has been boiled does not 
propagate cholera, which might thus be accounted for by the 
circumstance that all cyanides, when heated m the presence of 
water, are destroyed. Again, the undoubted efficacy of sulphuric 
and other acids in arresting the premonitory symptoms of the 
disease might be explained by the power mineral acids possess 
of decomposing cyanides; and the failure of acids in the fully 
developed disorder might be seen to depend upon the fact that 
acids, as such, only reach the alimentary canal, but not the 
blood. Lastly, we know that after storms, when the air is 
strongly ozonized, a decrease of cholera generally takes place ; 
probably, again, owing to ozone decomposing the cyanic poison. 
Might we not, therefore, in view of the failure of aU methods of 
treatment hitherto adopted, employ ozonized water as an anti- 
dote in the treatment of cholera ? And might we not use means 
of artificially ozonizing the air of our present cholera districts V ? 
— Lancet, Sept. 29, 1866. 



SNOW'S THEORY OF THE CAUSES OF CHOLERA EXPLAINED* 

AND ILLUSTRATED. 

By Dr. B. W. Richardson. 

[From the Medical Times and Gazette, Oct., 1S65.] 

The first element of the theory is to the effect that cholera,- 
pathologically, is a disease exclusively of the alimentary canal ; 



21 

that the great primary change from healthy to diseased action 
is at first locally confined to the alimentary tract ; that on this 
there is rapid exudation of fluid matter from all parts of the 
body ; and that the collapse, cramps, coldness, and other exter- 
nal symptoms of the malady are but results of the abstraction of 
water from the tissues. 

The second element in the theory is, that the primar3 T change 
in the alimentary canal is always induced by the introduction 
into the canal of a specific poison. 

The third element is, that the poison itself is exclusively con- 
tained in the intestinal exoetaof the infected person — that is to 
say, either in the vomit or the matters passed from the bowels. 
'There is nothing exhaled from the lungs, nothing from the skin 
of the cholera patient, that produces the disorder. It is all a 
question of the increase of poison in the alimentary canal, and 
ejection of poison from the canal. 

The fourth element in the theory is, that the poison is not a 
gas, is not a vapor, but a substance capable only of existence 
^either in the fluid or dried form of matter ; erg% it can only be 
■wafted a little way by the air, and when it is in a dried state it 
can only be carried long distances by being attached to articles 
-of clothing, or by being disseminated through the agency of water. 

These are the essentials of Snow's theory. They have been 
misunderstood because they have not been separated from cer- 
tain broad and practical conclusions with which he carefully 
connected them, and which have been much misrepresented. 

The leading misrepresentation of the Snow theory is that he, 
Snow, connected the spread of cholera purely with the supply of 
impure water.; and we constantly hear the theory spoken of as 
though the author of it, having no gr ounds to go upon, had a 
crotchet that because people drank bad water tney took the 
'©holera. This is an utterly false view of the case. Snow looked 
upon water as the great means by which the cholera poison was 
distributed. He said, and he proved, that if choleraic excreta 
be supplied to a community by and through the water which 
;that community drinks, such process will prove the most deter- 



22 

minate moans of introducing cholera into the community, anct ; 
that by such process great and sudden outbreaks of cholera wilt 
be secured. Acting on this thought, he actually advanced di- 
rectly to- the cause of tie cholera during the terrible Broad- 
street epidemic in London, and removing the handle of the 
pump by which the choleraic poison was being dispensed to 
many hundreds of the population, he stopped the plague as if by 
magic. But while he held this view of water as a means of 
propagating the poison, he enforced the opinion that there were 
other modes of transit. . He puts these modes into four groups. 
First, he held that the moist cholera excreta on the clothes and 
bedding of infected persons might be carried mechanically by 
the vapor of water, and might enter the nostrils and mouth in 
that form, and so be swallowed with the buccal secretion. It 
was in this way, he believed, that laundresses, engaged in wash- 
ing the clothes of infected persons, were so readily attacked. 
Secondly, he maintained thrat the poison might dry on infected 
clothing, and that from such clothing, on its being- unfolded or- 
moved, the solid- organic matter might escape in small substance- 
might be wafted a few feet in the air, and might, in fact, be ab- 
sorbed through the mouth by any one exposed to it. Thirdly, 
in respect to .nurses, persons who lay out the dead, and others* 
in atttendance, he urged that these might actually carry the 
poison- on their hands, and infect themselves by taking their 
food while their skin was not properly clean. In mines and 
other dark places where many persons congregate, this, he- 
thought, was a very common means of communication. Lastly,. 
he concluded that the very utensils — such as basins and cups 
used by the sick — might convey the choleraic matter, or even 
the cloths on which such utensils, imperfectly washed, have been 
dried. 

Thus there was not a process by which the matter of cholera 
could be conveyed, omitted by Snow in his thesis ; and we ven- 
ture to state that if all his precautions were carried out, cholera 
would soon be an extinct disease. 

Another cause of misapprehension of Snow's theory deserves- 



23 

notice and explanation. It was unfortunate that the author of 
the theory died while yet the question, to which we have next 
to refer, was under consideration. The question was, whether 
there exists a specific cholera cell capable of reproduction, and 
from the first of which all other cells proceed ; or whether there 
can be such a thing as a spontaneous generation of choleraic 
poison. It must be admitted that Snow, who was a staunch 
opponent of the doctrine of spontaneous generation, held by the 
cell theory, and was at first content to deal with the difficulties 
it suggested by comparing the origin of cholera poison with the 
origin of organic forms. Thus when he was once asked at the 
Medical Society of London, where the first cholera cell came 
from, he answered by begging the questioner to tell him where 
the first tisrer or the first upas tree came from ; adding, "1 have 
no power to answer questions on the subject of ultimate facts.' 
Later, however, in his life he was beginning to reconsider the 
question of the origin of the poisons, both of cholera and typhoid 
fever; and had he lived, we doubt not that, guided by his clear 
and vast intellect, and his unbiassed nature, he would have mod- 
ified his views in accordance with the natural truths that might 
have been presented to him. 

Is there any reason why at this stage of our knowledge we 
should ourselves modify that part of the Snow theory which 
treats of cholera poison as a reproductive cell capable of develop- 
ment only by reproduction ? We think there is, and we believe 
that, in fact, such modification widens and strengthens the basis 
of the theory. The position seems to be this, that all the points 
Snow originally taught — in reference to the alimentary canal 
being the seat of the disease, and the alimentary excreta the 
poison of the disease, as well as in reference to the modes of 
transmission of the poison — are confirmed; but that, in addition, 
such poison may, under peculiar conditions, be produced with- 
out the intervention of a first case. It is not, however, proba- 
ble, nor, as far as we can see, possible, for such generation of 
poison to commence in the living body itself The evidence seems 
to point to changes occurring in excreta that have been passed 



24 

trom the body. These excreta, during process of special de- 
composition, become transformed into poisonous matter, which 
by its presence tends to excite the same change, in continuation 
in similar matter, and which introduced, by accident, into the 
alimentary system of the living body, excites a new organic se- 
cretion and reproduction of poison. 

That there are periods when organic matters in decomposi- 
tion undergo peculiar transformation, or, in other words, that 
the process of decomposition is not a uniform process, always 
accompanied by the same products, is now generally accepted 
by the physiological world as a truth the importance of which 
can not be over-estimated. We shall hope, indeed, one day to 
show, on experimental demonstration, not only that organic 
matters yield particular products under particular conditions, 
but that those products are also particular causes of disease; 
and, we believe, that so far, and in accordance with this demon- 
stration, the theory otSnow will have to be modified. We shall, 
then, while retaining the essentials of his theory, accept them, 
minus the dogma that there must be, it matters not how -re- 
motely, some connection between one case and another case. 
We shall say that a case being in a community will communi- 
cate the disease if it be permitted so to communicate, and that, 
too, whether the case be an importation or a development ; but 
we shall not say that necessarily the first case was an importa- 
tion. 

In so far as practice is concerned, the whole experience of the 
present epidemic has been to show that choleraic poison, once 
developed, travels only in the manner suggested by Snow; and 
that all rational measures for suppression of cholera rest on a 
correct appreciation of his theory. Thus, at Constantinople, 
inieeted articles of clothing were washed in water which after- 
wards escaped into a drinking fountain ; thus, in Paris, the dis- 
ease is spreading by the aggregation of diseased with healthy 
persons; thus now, as in all former epidemics, it. runs that those- 
who attend most closely to the sick, and wash the infected 
clothing, die most speedily;, thus it is- that when the poison is, 



25 

introduced or developed in towns where it can not contaminate 
great supplies of water, the disease is localized and limited. 

The most striking illustration of the truth of Snow's theory 
has been given us at Epping, in the outbreak we described last 
week. There eleven persons were attacked and eight died. There 
the centre of the disease was on elevated ground ; so that a low 
position had nothing to do with it. There the disease occurred 
with a falling in the mean temperature; so that heat had noth- 
ing to do with it. There the disease struck and destroyed before 
the sufferers had time to feel dread; so that fear was not the 
cause. There eleven people were attacked, while hundreds in 
the district and some in the house escaped; so that no pervading 
atmospheric influence, especially affecting individuals, had any- 
thing to do with the disease. There was plenty to eat and 
plenty to drink ; so that poverty had nothing to do with the 
matter. That there were persons young and old, of different 
occupations and sexes ; so that age, sex and habit had nothing 
to do with the event. And yet eleven persons were attacked. 
To what central and single source can we look for causation ? 
It is before us. The sufferers drank from an infected well, or 
they came in contact with excreted matter from infec ed per- 
sons. It matters little whether Mr. or Mrs. Groombridge, in 
their travels, did or did not accidentally come in contact with 
excreted cholera poison, and did or did not communicate to the 
drinking water of the house such poison ; or whether that water, 
impregnated with organic matter derived from the closet of the 
house, became poisonous under a special form of organic decom- 
position, the results are the same, and while we deplore the 
catastrophe at Epping, we can not but express satisfaction that 
the outbreak occurred in a place from whence the choleraic 
virus could only be distributed amongst a limited number of the 
unfortunate. 



26 

OEIGIN, CAUSE AND PKEVENTION OP CHOLEKA. 
[From the Medical Times and Gazette, July 28, 1866.] 

At a late meeting of the Epidemiological Society, Dr. Kichard- 
son expressed the following views: 

"The positions he is prepared to maintain in respect to the 
cause of cholera and its propagation may be summed up as fol- 
lows : 

" The cause of cholera lies outside the organism. 

" The cause, when once in operation, can be carried from place 
to place. 

"It can be carried in clothing or on any solid substance. As 
dried scale, it may possibly be wafted a few feet by the air; but 
the great medium for its diffusion is water, in fluid or vapor. 

" The poison thus set in motion increases in the bodies of in- 
fected persons, but only in the alimentary canal. 

" The evidence is all to the effect that the poison escapes from 
the bodies of the infected only from the alimentary system. 

"The evidence points directly to the fact that in all cases of 
infection the poison is always, and only, received by the alimen- 
tary canal. 

"Incidents not a few, and of the most striking character, 
stand out to attest the mode of propagation of cholera, and to 
prove that by water supply the disorder was most commonly 
reproduced. In Constantinople one of these signal evidences 
was made manifest. Mr. Blogg, who was present during tho 
worst of the epidemic, has been good enough to furnish me with 
a fact that came under his own direct observation. It was this: 
The wearing apparel, the bedclothes and the mattresses of the 
sick were w T ashed at one of the fountains of the city, in the 
neighborhood of Tavatola. The waste-pipe of the fountain be- 
ing broken, this foul water became mixed with the drinking 
water of Tavatola. In one day after this event sixty persons in 
the small district supplied by this foul water were stricken with 
the malady. 

" In Paris, if all the facts had been published, similar truths 



27 

were laid open ; and one enterprising and eminent physician-,. 
Dr. Vacher, was so clear in his views on this subject that he? 
wrote to the Administration, begging to have water from the* 
public reservoirs that he might determine the organic impurity. 
The authorities, knowing necessarily what the disclosure would 
be — well aware, in fact, that the water in Paris was poisoned 
with organic matter derived from sewerage — refused, in a tone 
of the most peremptory kind, this simple request. 

"Snow did not sufficiently recognize that the vapor of water- 
was an active means of conveying the choleraic poison. This 
truth, however, has been abundantly proved since his death.. 
My friend, Mr. Watkins, of Towcester, has shown, in a paper 
marked by singular acuteness of observation, that in the last 
epidemic which occurred in this district the persons most con- 
stantly and fatally attacked were the women who washed the 
clothes of the sick. This circumstance, which has been largely 
confirmed by other observers, is almost a necessary occurrence. 
Unless every portion of the garments washed were actually ex- 
posed to 212° Fahr. instantaneously, the organic poison would, 
at lower temperatures, begin to pass off with the vapor, and 
those exposed to the vapor could only escape, I had almost said, 
by accident. 

" Snow, again, did not recognize the escape of the poison from 
the infected body directly in the form of w 7 ater vapor This is. 
a point of the greatest importance, because it determines the 
dissemination of the poison to a considerable degree. Thus,, 
when the temparature of the air is low, the fluid excreta con- 
dense on the body or on the clothing, and the poison is confined 
and limited in its effect; but when the temperature is raised, the 
poison disseminates readily in the vapor of water from the fluid 
exhalations. This is, I believe, without any further mystery, 
the reason why cholera always spreads most easily when the 
temperature is moderately high. 

" And for the same reason cholera spreads most easily in- 
erowded rooms. In these rooms the temperature is artificially 
raised',, and hot fluid foods, prepared often in the rooms, and aU 



28 

ways introduced Into them, surcharge the air with moisture and 
heat. In such an atmosphere the poison of cholera, in vapor of 
water, finds an equable and easy surface for distribution, vapors 
acting virtually as vacua, the one to the other. 

" Once more, in modification of Snow's view respecting the 
propagation of cholera, I think that larger experience, from the 
time he moved amongst us, has shown that the dried choleraic 
matter deposited in infected clothing ma}' be carried further and 
more readily than he supposed. 

{i Lastly, we may, perhaps, with some fairness believe that he 
urged rather too strongly the idea that the choleraic poison is 
often conveyed, on the hands of attendants, or on the utensils 
that have received choleraic excreta. 

" It will be well remembered in this place, that our distin- 
guished colleague held to no point so tenaciously as the non- 
spontaneous origin of what he called 'cholera cell/ This was a 
perfectly natural position for him to take, because, in his time, 
the germ or cell theory of disease was predominant, and because 
no suspicion even had been offered that organic poisons, or 
rather poisons derived from organic animal substances, could 
take any except the cell form. This being the prevailing thought, 
the question of the origin of the assumed cholera cell merged 
into the question "of the spontaneous generation of organic cells 
altogether j and as the universal evidence was opposed to spon- 
taneity, Snow, with the rest of his thoughtful compeers, held 
that the cholera cell always demanded for its reproduction a 
pre-existing cell. 

c< In this particular I believe him to have been incorrect, not 
from opposition to the truth, but from his wanting possession of 
those advances in physical medicine that have been made since 
he died. 

" An observation made originally by myself last year on the 
nature of the poisonous product of pyaemia throws a new and 
simple light on this question of the origin of organic animal 
poisons. In experimenting on the albuminous exudative matter 



derived from the diseased open surface of a patient suffering 
from pyemia, I learned that it was derived from the decompo- 
sition of albumnoid substance; I marked it as an 'animal alka- 
loid/ 1 named it ' septine/ and I showed that by its mere pres- 
ence on a secreting surface it transformed albuminous secretion 
into matter like unto itself. 

u These researches on the existence of an alkaloid occurring 
in the body during the existence of disease, have been this year 
singularly confirmed, physiologically, by Dr. Bence Jones' dis 
eovery of an alkaloid natural to the tissues, which is also de- 
rived from albumen, and which he has named quinoidine. 

" With the facts before us, that from albumen organic alka- 
loidai poisons can be formed, by mere physical change of ele- 
ment, the hypothesis of the necessity of cell growth, for the pro- 
duction of organic animal poison falls to the ground. We need 
not now enter on the question of spontaneous generation at all ) 
the formation of the poison, although from organic substance, 
has nothing to do with the origin of life ; the poison is a purely 
chemical change of organic substance ; a resolution rather than 
a construction ; a movement of the active or vital toward the 
inert or dead condition of matter. 

" In respect to cholera, the view that the poisonous matter is 
in the excreta in the form, not of an organic cell, but of an or- 
ganic animal alkaloid, makes what was before difficult perfectly 
simple. As the exuded or secreted matter from a wounded sur- 
face can, and does, under certain conditions of oxidation which 
we have yet, by a few simple experiments, to learn, produce 
pysemic poison, so the excreted matter from the alimentary 
canal is equally capable, under peculiar conditions of oxidation^ 
of producing an alkaloidal organic poison, which, soluble in 
water, but admitting of deposit on desiccation, passes easily 
from one person to another under the agency of those physical 
states which we have seen as peculiar to the development and 
progress of the epidemic." 



MICROSCOPICAL RESEARCHES ON" CHOLERA. 

The most important recent contribution to the pathology of 
cholera is the series of observations upon the morbid changes 
Which have occurred in cholera made, with the aid of the high- 
est powers and new methods of investigation, by Dr. L. S Beale, 
This eminent physiologist and skillful microscopist has entered 
Upon this inquiry, he states, as a scientific observer who has 
neither formed nor adopted any views concerning the nature or 
treatment of the disease. 

", In this inquiry," he says, "if seems to me desirable to start 
from the alimentary canal. Every one who has seen cholera 
has been struck by the remarkable character of the matter dis- 
charged from the intestinal tube, and those who have made post- 
mortems are familiar with the fact that the small intestines 
•almost always contain a Considerable quantity of pale, almost 
colorless, gruel, rice or cream-like matter. This has been proved 
to consist almost entirely of columnar epithelium, and, in many 
cases, large flakes can be found, consisting of several uninjured 
epithelial sheaths of the villi. I have often found such sheaths 
in the stools in previous epidemics, and probably every one who 
has carefully observed the disease will have inclined toward the 
opinion that in bad cases it is probable that almost every villus, 
from the pylorus to the ileo-csecal valve, has been stripped of its 
epithelial coating during life. 

The alteration in the apparatus concerned in the absorption 
of all nutrient matters from the intestinal canal, and the changes 
accompanying it and preceding it, are probably sufficient to ac- 
count for death by collapse. Most important, therefore, it is to 
ascertain, if possible, the several phenomena of which the denu- 
dation of epithelium is the climax, and the order in which they 
occur. These important organs, the villi, are, in a very bad 
case, all, Gr nearly all, left bare, and a very essential part of 
what constitutes the absorbing apparatus is completely de- 
stroyed. If only a considerable portion of a villus was denuded, 
Reparation might doubtless occur by new growth from the cells 
which remained, but if the villus was entirely stripped, it is more 



si 

probable that it would waste, and its place be at length occupied 
by a new one, which would grow from its base, than that epithe- 
lium would grow anew from its bare surface. It is probable 
that the extent of this process of denudation determines the 
severity or mildness of the attack. If a great majority of the 
villi have suffered, it is scarcely reasonable to consider recovery 
more probable than it would be atter a very extensive burn or 
scald. We shall have to inquire what is the proximate cause of 
the denuding process. Why does the epithelium drop off? What 
circumstances cause it to become detached ? The process may 
be due to violent contraction of the muscular fibres of the villi 
and the retraction of the villus within its sheath ; but, although 
no doubt contraction occurs, it is scarcely probable that the villi 
would bo so generally and completely stripped as they are in 
severe cases. It seems- more probable that the epithelium may 
become detached in consequence ot the almost complete cessa- 
tion of the circulation in the capillaries beneath, but the death 
of the cells may occur in consequence of their being exposed to 
the influence of certain matters in the intestine or in the blood, 
in which case they would simply fall off. These and many more 
hypotheses will have to be considered in the hope of finding the 
true explanation oi the fact. 

It ought not, I think, to be too hastily concluded that this 
abundant removal of epithelium is tho indication of the occur- 
rence of active elimination from the intestinal surface. For, in 
the first place, it must be remembered that the villi are not, in 
their normal state, organs of secretion or elimination but active 
organs of absorption ; while, on the other hand, Lieberhuhn's 
follicles, which open in the intervals between the bases of the 
villi, are secreting organs. Now these follicles, so far from be- 
ing denuded, are choked with epithelium. It is possible, how- 
ever, that there may have been a tendency upon the part of 
these cells to separate matter from the blood, but it seems im- 
probable that the columnar cells which form the bulk of the cel- 
lular elements of the contents of the small intestine, and which 
unquestionably came from the 7illi, should have been engaged 



32 

In such an office. Secondly, I would remark that the pabulum 
passes through the columnar cell in a direction from its free to- 
ward its attached surface, or from the intestine toward the blood. 
If, therefore, it eliminates or separates anything from the blood, 
the flow must take place through it in a direction the verj- op- 
posite of that which is constant during its life. Is it not im- 
probable that this should be the case ? In short, it seems to me 
that evidence in favor of the view that the removal of the epithe- 
lium from the villi is an elirninative act is still wanting. By 
the denudation a raw surface becomes exposed, just as in the 
case of the cutaneous surface after a burn or scald, except that 
the villi are completely bared, which is not the case with the 
skin. No one would argue that the elevation of the superficial 
layers of the cuticle, and effusion of serum beneath, consequent 
upon a burn, resulted from elimination. We are, to some ex- 
tent, acquainted with the several steps of the latter process, but 
we have not as yet learned much concering the former. 

The removal of the columnar epithelium from the villi, and 
the consequent destruction of the mechanism connected with ab- 
sorption, are broad facts in cholera which deserve the most mi- 
nute and careful study. We might well consider how this denu- 
dation may be prevented or retarded, and, having taken place, 
what fluids should be brought in contact with the naked sur- 
face — oily fluids, fluids containing salt syrup or glycerine, so as 
to make them of about the specific gravity of the serum, or ordi- 
nary serum itself, which la^t would probably be most effica- 
cious — or whether it would not be better, until we know more 
of the matter, to let the denuded villi remain perfectly quiet, 
and allow the small intestine to rest, in the hope that the dam- 
age may be repaired. But is it not reasonable to hope that a 
thoroughly minute investigation into the circumstances which 
probably immediately precede this denudation of epithelium 
would enable us to form a notion of its nature, and to adopt the 
means which were likely to restrain it ? A knowledge of the 
changes occurring after the denudation and destruction of many 
villi will probably teach us much concerning the nature of " sec- 



33 

ondary fever/' and enable us to place the patient under condi- 
tions most favorable to his recovery. The consideration of the 
mere fact of there being a raw denuded surface throughout a 
considerable extent of the alimentary canal suggests the pro- 
priety of not introducing anything into the intestines. The 
question concerning the alteration in the villi is a most interest- 
ing one, and it is worth while to spend time in searching for new 
facts, and in trying new experiments which may help us to an- 
swer it. But the subject is a very extensive one, and has many 
ramifications, each of which must be carefully considered in 
detail. 

Remarkable changes have occurred in the smaller vessels, es- 
pecially in the capillaries and small veins of the villi and sub- 
mucous tissue, and these changes can be readily demonstrated. 
The blood-corpuscles aj pear to have, in a great measure, been 
destroyed in the smaller vessels, and in their place are seen clots 
containing blood-coloring matter, minute granules, and small 
masses of germinal matter evidently undergoing active multipli- 
cation, but the nature of which has yet to be studied. Some of 
the arteries are contracted, but here and there small clots desti- 
tute of blood -corpuscles may be seen at intervals. Drawings of 
these will be published. 

On the other hand, the nerves and the ganglia, so numerous 
between the muscular and mucous coats of the small intestine, 
exhibit a natural appearance, so that I should not be able to dis- 
tinguish a ganglion taken from a cholera victim from one taken 
from a perfectly healthy person of the same age whose life was 
destroyed by accident. The nerves and ganglia, and the tissues, 
for a short distance around the smaller vessels, are, in many 
situations, stained with altered and dissolved blood-coloring 
matter. — Medical Times and Gazette, August 4, 1866. 

In a second article {Medical Times and Gazette, August 18th,) 
Dr. Beale states that the columnar epithelial cells found in great 
number in the rice-water evacuations and small intestine after 
death from cholera, do not always exhibit the same characters, 
nor are they of the same size in every case. 
c 



u 

He adds : "In almost all the cases of cholera I hare }~et ex 
amined there is evidence of chronic structural changes in the 
tissues of the intestines, and I think we shall be led to conclude 
that in most of the cholera victims important morbid alterations 
have been going on for months, and, in some instances, for }-ears, 
before death. In some cases it is probable that', had the indi- 
vidual escaped cholera, he must have succumbed to some other 
malady within a short period of time. The columnar epithelial 
cells often exhibit evidence of chronic change) they seem to be 
stunted, and, in many instances, the nuclei are much smaller 
than in health. In the intervals between their atta bed extrem- 
ities one fails to find those smaller and younger cells which in 
the healthy state gradually grow up to take the j.lace of those 
cells which are removed, and give origin to new cells, which in 
their turn become developed. So also it is to be observed that 
the masses of the germinal matter, so numerous mar the sur- 
face of the healthy villus, are almost absent in many of these 
cases of cholera. And there are other avid verv striking changes 
in the structure of the affected villi which I shall describe fully 
in other communications." 

In one case, that of a child fifteen months old, Dr. B. found 
the epithelial sheaths of the villi very distinct and perfect, but 
the cells did not exhibit the characters seen in other cases, 
"They contained numerous oil-globu'.es, some of which were of 
considerable size — a fact which, perhaps, justifies the inference 
that these particular cells were active and concerned in absorp- 
tion shortly before death, which certainly is not usually the 
case in cholera. The above inference is inferred by the charac- 
ter of the villi existing in this particular instance In most eases 
the fresh cells seem to be almost destitute of oil-globules, and 
many present a shriveled appearance, as if they had not been 
very active for a long time before death. There seems, indeed, 
to be the same sort of difference between some of these cells in 
•cholera and healthy columnar epithelial cells that is observed 
between the epithelium of a cirrhose and that of a healthy liver 
or kidney. ' * * '* 



MHH 



"35 

■<t A/mongst the epithelial cells and upon their surfaces, if not 
in their substance, are multitudes of bacteria. Bacteria are 
found in the dejections during life, and in the vomit, and in 
every part of the alimentary canal two hours after death. 

u It is probable that these organisms are developed in the in- 
testine in vast numbers during life." * * * 

,{ The falling off of the epithelial cells can not be attributed to 
the influence of bacteria, nor i3 it probable that these organ- 
isms are concerned in the production of cholera. Bacteria are 
found often enough in undigested or imperfectly digested food. 
In dyspeptic infants they occur in vast numbers in every part 
of the alimentary canal; and in temporary stomach derange- 
ment the matters ejected by the stomach or passed per anum 
-contain them in enormous quantity. They have been observed 
hj Dr. Gi'bb even in the milk immediately it was removed from 
the breast of the mother, and must have been developed while 
the milk remained in the mammary gland. They are always 
present in the fluids of the mouth, and are not uncommon in the 
contents of the stomach, though it is doubtful if they multiplj' in 
a perfectly healthy condition of the gastric mucous mem- 
brane. It is not very surprising that bacteria should be present 
in the cells of columnar epithelium in certain cases, seeing that 
their germs- are always present in the old cells of squamous epi- 
thelium in the mouth. They invade these columnar cells from 
without, and live at their expense, just as they invade the epithe- 
lial ce^ls of the tongue, and as simple fungi invade the cells 
of higher plants and animals when these cells begin to decay or 
lose, through disease, their healthy pover of resisting invasion. 

u Bacteria are constantly found in every part of the living 
body where a tissue is no longer permeated by the fluids whose 
office it is to maintain it in a state of integrity. Soon after the 
currents of fluid have ceased, especially where the organic ma- 
terial is soft and easily decomposed, bacteria make their appear* 
ance, and grow and multiply rapidly. Nor is there a tissue or 
organ in the inmost parts of the body in which these orgonisms 
may not, within the course of a few hours., make their appear- 



m 

ance. The germs are there , but so long as the normal state of 
things continues, these germs are prevented from being de- 
veloped. 

" These simple living organisms are, without doubt, destroyed 
in the healthy condition, although their germs may resist de- 
struction. If- the latter were to get into the healthy blood, they 
would not multiply, but toward the close of many exhausting 
diseases, both in animals and man, after the blood has under- 
gone important changes, they would be found in great numbers^ 
It is, however, doubtful if in any case they can be regarded as 
the cause of the disease or the muteries morbi, and it is far more 
probable that a change takes place before these organisms can 
multiply in the blood, and that a condition of things becomes 
established which is favorable to their growth and multiplication, 

" There is, then, I think, no good reason for supposing that 
the bacteria in such numbers in the alimentary canal in cholera 
have anything to do with this disease or with the falling off of 
epithelium from the intestinal or other mucous membranes. 
Bacteria are developed in organic matter which is not 
traversed and protected by the normal fluids of the body, and 
they invade the cells and textures in cholera, after these cells 
and textures have undergone serious prior changes, just as they 
would invade textures removed from the body altogether. Nor 
would it be in accordance with known facts to infer that cholera 
was due to the invasion of some peculiar form or species of bac- 
terium/' * * * 

"Cholera seems to be so constantly associated with the re- 
moval of columnar epithelium from the villi, that we have been 
led to look upon this as one of the essential phenomena of the 
disease. Although there may be no actual diarrhoea, this 
epithelium is found in quantity in the intestine after death. It 
may be said that this removal of epithelium occurs immediately 
after or only just before death, but the great number of colum- 
nar epithelial cells and entire sheaths of the villi so frequently 
found in the rice-water evacuation, giving to it its peculiar' 
character, proves that such a notion is not tenable. Can cholera 



B7 

'■exut without the villi being denuded of their epithelium, is a 
question which, as far as I know, has not yet been answered, but 
which must be answered before we can form a correct notion of 
the nature of this most wonderful disease. I do not think there 
is any other morbid condition in which this striking change is 
observed — at any rate, to the extent and frequency it is met with 
in cholera. It seems, however, likely, that where these changes 
in the blood occur very quickly indeed, so as to cause death by 
stagnation of the blood in the capillaries of important organs, 
there might not be time even for the removal of the epithelium 
from the villi, just as we may have death from the small-pox or 
scarlatina without any eruption. 

" With reference to the denudation of the villi, it must be 
borne in mind that the throwing off of the epithelium is not 
confined to the villi of the intestine, or to that of the intestinal 
mucous membrane generally. The process affects the mucous 
membrane of the gall-bladder and larger gall-ducts; that of the 
■bladder ; ureters, and pelvis of the kidneys, as well as of the Fal- 
lopian tubes, uterus and vagina. In short, there seems a ten- 
dency to the removal of epithelium from the surface of all the 
soft, moist mucous membranes ; not, it must be remembered, of 
the epithelium which is specially concerned in elimination, but 
rather of that which lines the ducts of glands and cavities which 
■may be included in the category of the ductal portion of the dif- 
ferent secreting glands. 

" On the other hand, there is no evidence of the increased for- 
mation or more rapid removal of the secreting epithelium in the 
various glandular organs. The follicles of the mucous mem- 
brane of the stomach and intestine, those of the salivary glands 
and pancreas, the tubes of the liver, kidney and other glands 
still retain their epithelium ; nor have I been ab'e to demonstrate 
in these varieties of glandular epithelium any appearance pecu- 
liar to cholera. Indeed, so far as I have yet been able to ob- 
serve, it would be extremely difficult to distinguish many secret- 
ing cells taken from the bodies of cholera victims from perfectly 
he&lthy cells/* 



38' 
CHOLEEA. 

Extracts from a Review of Cholera By the Editor of the Medical News aad Library,. 

August, 1866. 

The symptoms of cholera have been so often and fully de- 
scribed that it is unnecessary to dwell further on them; enough 
has been related to demonstrate that the alimentary canal ex- 
hibits the earliest and most serious manifestations of disease* 

Let us now inquire whether the morbid lesions, found after 
death, lead to the same conclusion. 

There is a remarkable uniformity in the statements of ob- 
servers in regard to the pathological appearances met with in 
those who have died of cholera. We have in our library over- 
one hundred and fifty works on the disease, and an examination 
of them has fully satisfied us, as has also oar personal observa- 
tion, that the only differences noticed result either from acci- 
dental complications or from the period at which death takes 
place— whether it occurs early or later in the algide period or 
after reaction. 

No constant or marked lesions are found in the brain or ner- 
tous sj^stem, lungs, heart, liver, spleen, kidneys or genital organs. 

Brain and Nervous System. — Virehow met with no structural- 
changes in the brain and spinal cord ; Reinhardt and Leubuscher 
report the cerebral substance to be healthy, as do most other 
writers. 

M. Bouillaud says that he has recently dissected the nerves of 
the lower extremities, in a patient who had experienced violent 
cramps, and that he found them in a state of the most perfect 
integrity. 

Alimentary Canal. — Through the whole extent of the alimentary 
tube, horn, the pharynx to the anus, there is constantly found,, 
after- death, marked lesions, varying only according to the 
period at which the- patient has succumbed. When death occurs 
early, either from feebleness of constitution in the victim, or 
from the violence of the attack, the mucous membrane is found 
in a state of t^persejnia, to a greater or less extent, with punctu- 
ated or arborescent, redness and with enlargement, of all the nuv 
cous follicles. 



39 

If death occurs later, the hyperemia has often disappeared, 
the mucous membrane has become pallid softened and denuded, 
to a greater or less extent, of its epithelium, as first pointed out 
by the late Professor Horner, of the University of Pennsylvania, 
and since confirmed by many other observers. It is the debris 
of the epithelium which constitutes the flocculi so characteristic 
of cholera evacuations. 

Dr. Charles T. Jackson, who attended the pathological exami- 
nations of Professor Wagner, at Vienna, states that "the uvula, 
tonsils and pharynx were covered with granulations, as also the 
base of the tongue. " 

" These granulations," he adds, a vary in size from that of a 
pepper-corn to that of a pea, and are probably the mucjus folli- 
cles altered by inflammation/' Mr. Fergus, who attended the 
dissection of two hundred cholera subjects by Professor Wag- 
ner, states that the mucous membrane of the pharnyx was often 
of a deep purple from injection of its vessels "The mucous 
membrane," ho adds, " seems always, in acute cases, as if swol- 
len in its whole extent; from place to place it was a bright red 
from numerous vessels. — Lancet, June, 1832. 

The mucous membrane of the stomach is covered with a 
tenacious mucus, largely mixed with exfoliated epithelium, and 
over its whole circumference it presents a multitude of small, 
white granulations, slightly grayish, having a very regular hem- 
ispherical projection. These granulations have no regular ar- 
rangement, and everywhere disseminated, they are still more 
numerous in the duodenum and jejunum than in the stomach. 
M. Serres says that they are so numerous and developed in the 
small intestines that the whole mucous membrane seems as if 
made up with them; their number decreases toward the large 
intestines. On dissection these granulations are found to be the 
follicles of Brunner distended by a white, turbid fluid, and three 
times their natural size. This development of the follicles of 
the mucous membrane appears to be constantly met with in the 
early stages of the disease, even when death occurs wi:hin 
.twenty -four hours. 



40 

u The isolated follicles or glands of Brunner," says M Foul- 
laud, "are those particularly which we observe more or less 
tumefied and developed; nevertheless it is not uncommon to 
meet, at the same time, that lesion in the plates ot Pej^er or the 
clustered follicles. This hypertrophy, this species of erection of 
the follicles of the mucous membrane of the digestive tube, pre- 
vails, sometimes, through the whole extent of this immense 
membrane; and this gastrointestinal eruption, sometimes dis" 
tinct, at others confluent, imitates, to a certain extent, variolous 
eruption in its first stage. The number of follicles developed, 
when the eruption is confluent, is truly incalculable. We will 
only say, that any one who has seen this kind of eruption will 
not consider the calculation of M Lelut, by which the whole 
number of follicles in the alimentary mucous membrane is esti- 
mated at forty-two thousand, to be exaggerated. The size of 
these follicles thus tumefied varies from that of a small millet- 
seed to that of a hemp-seed. Their form is rounded and granu- 
lar. Many of them have a blackish point at their centre. There 
are some which do not offer this character, and MM. Serres and 
Nonat, who have published some researches of great interest on 
the subject under consideration, think, as is known, that these 
granulations are not follicles, but intestinal papilla? in a state of 
tumefaction. We have studied with some care this point of 
pathological anatomy; and we are certain that an immense ma- 
jority of the granulations with which the mucous membrane is 
covered, are really enlarged follicles, but we will not affirm that 
those on the summit of which there is no perceptible black 
point, and which marks the opening of follicles, are actually the 
same. The color of follicular granulations is commonly a gray- 
ish white; at their bases a more or less considerable injection is- 
frequen^y met with." 

"Mr. Fergus, to whom we have already referred, states that 
in those patients who "had died after a few hours' illness, the 
glands of the pharynx and back of the mouth, those of the in- 
testines, from the cardia to the anus, were much, but simply,, 
enlarged ; those of B runner were elevated above, and stood clear 



41 

out from the mucous membrane ; those of Peyer were raised 
about half a line or a line, and their surface was uneven. They 
were alwaj's of a pale color, and of a uniform texture when cut 
into ; they stood in no relation whatever to those parts of the 
intestine where congestion had taken p'ace; but they seemed to 
have some connection with the production of the thick mucus, 
because the glands were most developed in those subjects and 
in those places where the mucus was most abundant. When 
the contents of the canal were more fluid, these glands were no 
longer so distinct. — Lancet, June, 1832. 

Incipient ulcerations are also occasionally met with in the 
intestinal follicles. 

The whole iniestinal tube is generally more or less distended 
with a whitish, turbid fluid, similar to that discharged by vomit- 
ing and stool, and which fluid is pathognomonic of cholera. In 
the stomach, besides the choleraic fluid, there is found, usually, a 
very considerable quantity of glairy mucus, more or .ess adher- 
ing to the mucous membrane j sometimes in place of this a layer 
of creamy matter is to be found, similar to that hereafter to be 
noticed as met with in the intestines. M. Bouillaud says that 
he has several times seen in the stomach a yellowish or greenish 
bile. 

Among the pathological changes found on post-mortem ex- 
amination, that in the blood is most striking. Its consistence 
is much greater than normal, and its color very dark. Its speci- 
fic gravity was found by Dr. Garrod to be from 1068 to 1081, 
while the maximum of healthy blood, according to Becquerel 
and JRodier, is 106'2" (London Jour. Med., vol. i. p. 409). Rein- 
hard and Leubuscher observe "the blood contained in the cavi- 
ties of the heart was, in the majority of cases, coagulated into a 
dark homogeneous mass, with fibrous coagula extending into the 
large vessels. Yirchow's statement that these coagula contained 
a large number of colorless corpuscles, was confirmed by our* 
own observations. The large venous trunks, and the veins of 
individual organs, were full of blood, whilst the arteries and 
capillaries were for the most part empty. This fulness of the 



42 

veins was mova marked in cases where death followed quickly 
upon the commencement of reaction after the cold stage." 

The investigations of Dr. Garrod (op. cit.) on the blood have 
led him to the following conclusions : 

"1. That in cholera the physical characters of the blood are 
changed, and its tendency is to become thicker, tar-like, and less 
coagulable. 

" 2. That the proportion of water is much diminished. 

" 3. That the specific gravity of the serum is very high, which 
is due to the increase of the solid portion of the serum, and es- 
pecially of the albumen ; and that this fluid also tends to become 
less alkaline in its reaction. 

" 4. That with regard to the salts of the serum, some doubt 
exists as to their excessive diminution. 

u 5. That urea sometimes exists in cholera blood." 

The analyses of Professor Hermann, of Moscow, of MM. Eose 
and Wittflock, of Berlin, and of Dr. Clanny, of Sunderland, also 
show that there is a great deficiency of water in cholera blood. 

The experiments of Dr. Reyer show that the serum of cholera 
blood is less alkaline than that of healthy blood; and Dr. 
O'Shaughnessy states that it is nearly or entirely deficient in its 
alkaline ingredients. " Of the free alkali contained in healthy 
serum/'' he says, u not a particle is present in some cholera cases, 
and barely a trace in others." M. Lassaigne, of Paris, in his 
chemical examination of choleraic blood, found it to contain 
only a fourteenth of the usual quantity of fibrin.' 7 

This change in the condition of the blood does not occur, how- 
ever, early in the disease. This has been conclusively shown 
by Schmidt, and also by Dr. O'Shaughnessy, who availed him- 
self of the second eruption of cholera in London, to repeat his 
chemical inquiries relative to this disease on a most extensive 
scale, with a view, if possible, to decide the important question, 
whether the alteration of the blood be primary or secondary, 
and to ascertain what are the conditions of the blood in the sev- 
eral stages of the disease. His investigations show, that — 

" 1st, in the premonitory symptoms, no alteration of the blood 



43 

exists; 2$, in the eases in which the evacuations are trivial^ 
and cramps form the prominent symptoms, the blood is also un- 
altered • 3d, the alteration of the blood, consisting in loss of 
water, and saline matter, only occurs in the collapsed cases pre- 
ceded by excessive rice-water evacuations ; 4th, the alteration 
of the blood gradually disappears or increases in the fever stage, 
according to the .aggravation or amelioration of the symptoms."" 
— Lancet, August, 1832. 

Dr. Clanny also found the quantity of water in the blood 
scarcely at all diminished in the incipient stage of cholera, and 
Mr. Prater says, that in four cases in which he examined the 
blood in this stage, that fluid seemed to redden, contract, and. 
to contain the ordinary proportion of water. The change in the 
blood then occurs late in the order of symptoms. 

The character of the evacuations in cholera is deserving of at- 
tention. The following are the results obtained by Dr. Clanny, 
from an analysis of the dejected fluid : Water, 989 ; fibrin, 6 * 
carbonate of soda, 3; animal extractive) 2; total, 1,000. (Op* 
Git., p. 112). 

According to Dr. O'Shaughnessy, "all the salts deficient in 
the blood are present in large quantities in the peculiar white 
dejected matters." MM. Eose and Wittfiock,. of Berlin, and Dr. 
Kirk, of Greenoch, also state the dejections to be alkaline. The 
existence of fibrin in the dejections is shown also by the analyses 
of Dr. Christie in India, and Dr. O'Shaughnessy. 

The greatest quantitative loss, as observed by Dr. Goodeve, 
(doc. cit\, p. 160,) "which the blood suffers is in its watery ele- 
ment. For every 100 ounces passed in the fluid evacuation^ 
stage, the loss to the blood is in water 98 to 99 ounces, and of' 
salts nearly or about one ounce. The salts exuded are the chlo- 
rides of sodium and potassium, phosphate of soda, carbonate and. 
sulphate of soda, bearing a proportion of seven or eight parts in 
1,000, a proportion nearly resembling the quantity in the blood 
within the vessels. The earthy phosphates do not pass through 
the mucous membrane as in health." 

"It will be seen," he further observes, " that the intestinal 



44 

surface removes from the blood a large quantity of water, a 
small quantity of animal matter, and much saline matter; doubt- 
less causing great change in the blood, and in the behavior of 
the different elements of the blood to each other." 

The influence which the water in the organism exercises on 
physiological phenomena, and the prejudicial results which fol- 
low from its loss, is not generally fully appreciated. Eobin and 
Verdeil have shown that water was an anatomical element of 
the system. Bernard asserts it to be an essential component of 
all living organisms — that it is the necessary vehicle for the ma. 
terials which enter into the double movement of nutrition and 
excretion, without which life cannot be maintained. " Indepen- 
dently of their special properties/' M. Bernard remarks, " the 
organic fluids are allied by a general character ; all owe their 
first ptrysiological importance to the water they contain.; before 
being useful in consequence of the substances which they hold 
in solution or suspension, they are first useful as fluids." 

There is little ground for surprise, then, that the loss by the 
blood, in cholera, of so large a portion of its most important ele- 
ment should be followed by disastrous consequences — that life 
can not, under these circumstances, be any longer maintained. 

The condition is worse than after hemorrhage, for in the lat- 
ter the blood in the system, though deficient in quantity, is nor- 
mal in quality, while in cholera the blood is no longer suitable 
for the jmysiological functions of maintaining life. 

The chemistry of the vomited matters has been less investi- 
gated. 

A question which would have been regarded as of more im- 
portance formerly than at the present time, is, whether the se- 
cretions into the intestinal canal are the result of inflammatory 
action, or a passive serous hemorrhage, or osmosis. Dr. Gall 
(op. cit., p. 118) seems to us, to take the correct view of the 
subject in stating that "an examination of the fluids effused 
from the mucous membrane gives no evidence of active plus" 
•matic changes taking place in them. On the contrary, the large 
amount of fluid thrown out, its low specific gravity, and its 



45 

other physical characters, indicate an almost passive exosmosig, 
as through a dead membrane." 

A deficiency of water in the blood, and also the law of the 
animal economy that the augmentation of one secretion pro- 
duces a proportional diminution in others, explains the diminu- 
tion or suppression of the urine and various other secretions. 

Such seem to us, as indicated by the symptoms, to be the 
series, relation and physiological explanation of the essential 
symptoms of cholera. 

The post-mortem appearances concur fully with the symp- 
toms during life in showing the essential lesion in cholera — the 
one never absent in the disease — to be an effusion upon the in- 
ner surface of the intestinal tube of a serous fluid, containing 
the debris of exfoliated epithelium, which is afterwards rejected 
by vomiting and purging ; and that this fluid is the product of 
an alteration equally constant, at least in its early stage, which 
alteration consists in the development of the secretory follicles 
disseminated over the digestive tube. 

The exaggerated secretion of the intestinal follicles must have 
been necessarily preceded by an afflux toward these follicles, 
and it must also be necessarily accompanied by that state of tur- 
gescence of the secretory organs accompanying all augmented 
secretions —an active state to which Bordeu has called the at- 
tention of physicians, and of which post-mortem examinations 
have always shown the traces when death has not occurred too 
late. 

These follicles gradually increase in size under the influence 
of this fluxion to them, their secretions are augmented, and thus 
is produced the serous diarrhoea which constitutes the initia- 
tory stage of cholera. As soon as the secretion is increased in 
the whole digestive tube, to a sufficient extent to quickly sub- 
stract from the blood a large portion of its elements, the chol- 
eraic symptoms appear. Previous to this the loss, which the 
blood suffers is slight, and absorption repairs it continually. 
Thus the intensity of the general symptoms is, ceteris paiibus, 
in proportion to the suddenness of the serous secretions. A per- 



lOia in whom tlrese secret] ons occur slowly sudors less at the 
end of three or four days, although he may have lost a large 
quantity of serum, than another would at the termination of an 
hour, in whom the deperdition has taken place suddenly, even 
though he had lost less serum. For the same reason the disease 
becomes very speedily fatal in those who have scarcely any dis- 
charge by vomiting or stool, but whose alimentary tube is sud- 
denly filled b} T the product of the secretion, and this especially 
in persons whose vital powers are enfeebled by previous disease, 
irregular habits, etc. 

The blood deprived of its water by the profuse secretions into 
the bowels, becomes thickened ; and in proportion as it is ren- 
dered thick and viscid, and the propulsive power of the heart is 
enfeebled by the excessive choleraic secretion, will the circula- 
tion be diminished. The diminution of the circulation through 
the lungs causes derangement of respiration— the blood deprived 
of its saline matter by the secretions in the bowels, the oxygen 
of the air can not effect in it those changes which this agent or- 
dinarily produces upon it in the lungs; the proper changes of 
the blood in the lungs being thus imperfectly and ultimately not 
at all effected, the portion of this fluid which reaches the left 
side of the heart is similar to that sent to the lungs by the right 
side of that organ. The suspension of the general circulation, 
and the dark color of the blood, produce a blueness or bronze 
color in those parts in which the thinners of the skin permits 
the color of the blood to be partially seen — as occurs in as- 
phyxia. The circulation being suspended, animal heat can no 
longer be generated, and hence the body becomes cold. The 
profuse secretion in the intestinal canal is effected at the ex- 
pense of the water of the blood, which creates a demand on 
every part of the system which can supply this waste. Hence 
the muscles, cellular tissue, etc., are deprived by absorption of 
their water}' constituents, causing a shriveling of certain parts, 
as of the fingers and toes, sinking of the eyeballs, etc. This 
same condition is also observed in some profuse hemorrhages ) 
our esteemed friend* the late Professor Dew T ees, notices it as oc- 



etirrlng in uterine hem- rrhnge. Thus are the phenomena of 
collapse produced. 

Finally, a confirmation of the correctness of our views is fur- 
nished by the class of persons most obnoxious to cholera, Thus 
we find it is individuals whoge gastro-intestinal mucous mem- 
brane is in a state of excitement or irritation from the excessive 
Use of spirituous drinks, from the ingestion of indigestible food, 
etc., who are the most frequent subjects of cholera. In such 
persons also the course of the disease is rapid— the primary 
stages are scarcely observed The reason of all this is evident. 
The first effect of the choleraic poison is to irritate the digestive 
mucous membrane, and to establish a fluxion 'to it. Spirituous 
liquors, indigestible food, produce the same effect; their action 
is in the same line, then, with the agent producing cholera. 
Drunkards, those who indulge in indigestible aliment, then, have 
their gastro intestinal mucous membrane in a state of irrita- 
tion — they are in fact in a condition nearly identical with the 
first stage of cholera — such persons are known, indeed, to have 
habitual diarrhoea, Irritation of the digestive mucous mem- 
brane, with its consequences, an afflux of blood to the part be., 
ing established, in such persons, on the addition of the influence 
of the cause of cholera, increased osmosis is at once induced, and 
the phenomena of the second and third stages of the disease 
promptly appear. Thai the disease should be generally fatal in 
the class of persons under notice, is not surprising; they usually 
fall victims to any disease with which they may be attacked. 

The analysis of the symptoms, the order of their occurrence^ 
and the post-mortem appearances the effects of agents on the 
alimentary mucous membrane, whose action is known to be irri- 
tating, and various facts in the history of the disease, all tend 
to prove that cholera is an irritation of the gastro-intestinal mu- 
cous membrane, always directed to the secretory apparatus of 
this tissue, and often involving the functions of nutrition and 
innervation of the same tissue. 

The varieties which are observed in this disease arise from 
the degree in which these several functions are deranged, and 



48 

to the extent and the portions of the alimentary mucous mem* 
brane in which the irritation predominates The degree to 
which the functions of nutrition and innervation are involved 
appears, in a considerable degree-, to be dependent on tempera- 
ment Thus it is observed that in persons of. sanguineous tem- 
perament the manifestations of increased secretion, whilst in 
those of nervous temperament those of lesion of innervation, as 
spasms, predominate. 

The peculiar fatality of this form of gastro-intestinal irrita- 
tion depends upon the extent of that irritation, usually from the 
pharynx to the anus ; and to nearly all the functions of the tis- 
sue being involved — secretion, nutrition and innervation. 

Such is the outline of what appears to us to be the tiue path- 
ology of cholera, as we presented them to the Philadelphia Med- 
ical Society in the autumn of 1832, and which we published in 
the Cholera Gazette of November 21, of that year We have 
now reproduced it with slight alterations and additional evi- 
dence in its support. After the reflection we have since given 
to the subject, it still appears to us to be in entire accordance 
with all that have been observed, to leave none of the phenom- 
ena of the disease unaccounted for, and to lead, moreover, to 
the only mode of treatment that can. lead to success. 



PATHOLOGICAL ANATOMY OF CHOLEBA. 
[Medical News and Library, September, 1866.] 

In the last number of this Journal we alluded to the observa- 
tions first made by the late Professor Horner, of the University 
of Pennsylvania, that, after death from cholera, the epithelium 
of the mucous membrane of the alimentary canal is found ex- 
foliated to a greater or less extent. In two valuable papers pub. 
Ii3hed in the American Journal of the Medical Sciences, for May 
and August, 1832, Professor Horner states that he found the 
following anatomical characters in the alimentary canal after 
death from cholera: 

"1. A copious vesicular eruption, entirely distinct from the 



49 

tumefaction of villi, muciparous follicles or glands, and which 
pervades the whole canal. 

" 2. A lining membrane of coagulated lymph, which exists in 
the small intestines, at least, if not in the stomach and colon 
also, and resembles in texture and mode of adhesion the mem- 
brane ot croup. 

" 3. Vascular derangements and phenomena which are con- 
fined almost exclusively, if not entirely so, to the venous system. 

" 4. An exfoliation of the epidermic "lining of the alimentary 
canal, whereby the extremities of the venous system are denuded 
and left patulous." 

The cr mpy or diphtheritic exudation on the mucous mem- 
brane has been also observed by Virchow, Cruveilhier, and is 
fully described by Reinhardt and Leubuscher. who state that 
they found the congested mucous membrane of the large and 
small intestine " infiltrated, to a greater or less extent, with a 
solid exudation, which, after Yirchow, we would designate 
'diphtheritic.' This exudation contained but little water, was 
of a grayish or yellowish white color, and under the microscope 
was amorphous. It was rendered translucent by acetic acid 
and caustic alkali, but resisted the action of the former for some 
time. The deposit began in the superficial layers of the mucous 
membrane, and was mostty confined to the membrane itself, but 
in certain parts it extended somewhat beyond, as in the small 
intestine where it filled up the spaces between the villi, fusing 
them together in a continuous mass, in which, by the aid of the 
microscope, the outline and tissue of some of the villi could oc- 
casionally be distinguished." * * * * 

The extent of the effusion varies extremely. "Those parts 
where the hyperemia has been most marked in the cold stage 
were principally affected. In the small intestine the ileum was 
the principal seat of the diphtheritic inflammation, particularly 
the vicinity of the ileo-cceeal valve, from which point it extended, 
lessening in intensity, to a 'variable distance upwards into the 
ileum or even into the jejunum." * * * *' 

" The exudation, without undergoing an3' degree of organiza- 

D 



60 

tiopj gradually softened, the tissue in which it was contained 
softened with it. The process of disintegration commenced on 
the surface, and by extension to deeper parts produced a loss of 
substance of variable extent, subsequently having the character 
of common ulceration. In general, however, the cases were 
fatal before the diphtheritic matter was. fully thrown off. (See 
Gull's report, pp. 57-53.) 

This diphtheritic exudation was also found on the lining mem- 
brane of the gall bladder by Pirogoff, Eeinhardt and Leubus- 
cher; and Briquet and Mignot record similar observations upon 
the occasional occurrence of inflammation of the gall bladder 
and ducts, with diphtheritic exudation upon the surface of the 
mucous membrane. 

Some of the anatomical characters described by Prof. Horner 
have not been noticed by other observers ; and with a view to 
further elucidate the subject, the College of Physicians of Phila- 
delphia appointed a committee during the prevalence of the 
disease in 1849 to investigate the subject, and their report is 
worthy of especial consideration. 

The subject was brought to the attention of the College on 
the 19th of June, 1849, by Prof. Jackson, who remarked that 
u our great object in the investigation of the pathology of cholera 
was to arrive at facts clearly and accurately established. At 
present all is doubt, speculation and hypothesis. The disease is 
now amongst us ; let us examine it systematically and thor- 
oughly, without prejudice, and unbiased by the authority of 
names or systems. What are the anatomical lesions in cholera ? 
We have it asserted, first by Dr. Horner, and subsequently by 
Dr, Boehm, of Berlin, that they consist in certain changes which 
occur in the mucous membrane of the alimentary canal, which 
are characteristic of the disease. Here then is something defin- 
ite to start with. Let us investigate the subject for ourselves, 
and ascertain whether the observations upon which the deduc- 
tions of the two pathologists just named, are based, are correct. 
The ordinary procedure of laying open the intestines, and hastily 
examining their internal surface with the naked eye, amounts to- 



M 

urig'; the parts to be examined must be macerated and in* 
jeered, and then examined by the aid ot the microscope. This 
is the course that has been pursued by Dr. Horner, who has 
pointed out the only true method of prosecuting the inquiry. 
To arrive at any definite results, this plan must be followed out 
by good anatomists and experienced microscopists. In this 
manner, and by such investigators, must the facts in relation to 
this subject be collected, and the result placed before the profes- 
sion in the form of a report. 

"Dr. Jackson moved, therefore, the appointment of a commit- 
tee to investigate the anatomical lesions of the intestinal mucous 
membrane in cholera, and report the result of their labors at a 
future meeting of the College." 

Under this resolution, Drs. Jackson, Keill, Pepper, H. H. 
Smith and Goddard were appointed the committee. 

At the meeting of the College held on the 4th of December 
following, Professor Jackson submitted a report, in which it 
was stated that 

" The ordinary autopsical examinations heretofore practised 
have failed to yield any satisfactory information, and are nearly 
useless for the purposes of science. 

"Extensive structural lesions may exist that can not be seen 
or very imperfectly discerned by the unaided sight, and without 
proper preparation. 

'■ It was determined by the Committee that the intestines) 
before being submitted to examination, should be finely injected, 
and subsequently inspected with the microscope. 

"This task was undertaken for the Committee by Dr. John 
Neill, Demonstrator of Anatomy in the University of Pennsyl- 
vania. The admirable manner in which he has performed this 
duty can be judged of by the beautiful preparations now on the 
table, which he has presented to the College for its museum. 

" The injections are made with turpentine colored with ver- 
milion. It was found by Dr. Neill that when he employed size, 
it did not penetrate well, and numbers of capillaries were not 
filled ) the same result occurred when Canada balsam was used. 



52 

It led, at first, to the supposition that the- capillaries were? 
destroyed by the disease. The method last adopted, as the fine 
preparations on the table demonstrate, show the perfect integ- 
rity of the capillaries. 

" A healthy intestine, taken from a subject who had died of 
pleurisy, was first injected as a standard of comparison. * *■ 

"The Committee, confining themselves strictly to the single 
object for which they were appointed, report the following facts 
as the result of their investigation. The preparations and draw- 
ings on the table will enable the Fellows to determine on the 
accuracy of the statement. 

" 1st. In the recent subject, the peritoneal co^t,. like all the 
serous membranes, was in all, remarkably dry. The lubricating 
serosity is deficient in the serous membranes. 

u 2d. The epithelial layer of the intestinal mucous membrane 
was, in all the specimens, either entirely removed, or was 
detached, adhering loosely as a pulpy layer mixed with mucus 
or an albuminoid substance. 

" 3d. Peyerian glands. Peyer's glands were developed to a 
greater or less extent in all the cases examined. * * 

"4th. Solitary glands. These were also developed and con- 
tained, in the recent subject, a minute quantity of white sub- 
stance. * * * * * * * 

" Villi. They are denuded of the epithelial covering, but are 
unchanged in other respects. * * * * 

6th. Capillary Vessels. These are entire and manifest no 
departure from their normal state. The appearance of the capil- 
laries of a cholera intestine is identical with those of the healthy 
mucous membrane when the epithelium has been removed. In 
the natural state the epithelium, from its thickness, conceals the 
injected capillaries. * * * * * * 

"In no instance was a vesicular eruption observed/' 

The foregoing facts, derived from the examination of twenty- 
five subjects, illustrated by preparations most carefully made by 
Dr. Neill, are of the highest value, and shed important light on 
the pathological anatomy of cholera. They have been strangely 



53 

overlooked, and we will therefore refer to the published transac- 
tions of the College, and also to the number of the American 
■Journal ef the Medical Sciences for April, 1850, in which will be 
found the report in full, with colored drawings, of Dr. Neill's 
preparations. 

Dr. NeilFs preparations presented to the College are still pre- 
served in their Pathological Museum at the Hall of the College. 

These investigations, as well as the facts already stated, fully 
demonstrate that the alimentary canal is the seat of the morbid 
actions which constitute cholera. Whether or not the cause of 
cholera, whatever it may be, acts primarily on the ganglionic 
nervous centre^, and through them on the intestinal canal, or 
its primary action is on the latter, we leave it to others to dis- 
cuss. Either theories will explain all the phenomena ; but as no 
lesions have been usually found in the ganglionic nervous cen- 
tres, while those in the alimentary tube are constant and serious, 
it seems questionable whether it is sound philosophy to go be- 
yond the latter or to seek for more causes than are sufficient to 
account for the phenomena. 

The Berlin pathologists, whose attention was particularly 
arrested by the occurrence of amorphous granular fibrin in and 
upon the a"ffected surface of the mucous membrane, regarded 
cholera as -a "destructive diphtheritic inflammation." We must 
agree with Dr. Gull that ''such generalizations, however plausi- 
ble, are of little value, and that we arrest inquiry by their adop- 
tion " the excessive exosmosis from the mucous membrane of 
the alimentary canal, by depriving the blood of its most impor- 
tant anatomical element — water — and its salts, suffices, in our 
judgment, to fully account for all the phenomena of the disease. 

Dr Gull, in his report, (p. 118), speaks of the loss of the epi- 
thelium as "in itself an unimportant change." We can not so 
regard it. On the contrary, we believe it to be a most disastrous 
condition; and disastrous exactly in proportion to its extent. 
Not on'y by the destruction of the mechanism of absorption 
which it involves, does it constitute the great obstacle to the 
restorative processes, preventing the supply to the blood of the 



5^§ 

materials it has lost, and rendering remedies inoperative; 1 bid* 
the irritation resulting, when a large surface is denuded, may 
of itself prove fatal, like an extensive scald of the skin,, even 
when very superficial. 

We are happy to quote in support of our views so high an 
authority as Dr. Lionel Beale, the first number of whose "Micro- 
scopical Researches, on Cholera w (Med. Times and Gaz., Aug. 4, 
i860) has reached us since the above article was in type. 

This eminent microscopist says: "Every one who has seen 
cholera has been struck by the remarkable characters of the 
Blatter discharged irom the intestinal tube, and those who- have 
made post-mortems are familiar with the fact that the small in- 
testines almost always contain a considerable quantity of pale, 
almost colorless, gruel, rice or cream-like matter. This has 
been proved to. consist almost entirely of columnar epithelium, 
and, in very many cases, large flakes can be found, consisting 
of several uninjured epithelial sheaths of the villi.. I have often 
found such sheaths in the stools in previous epidemics, and 
probably every one who has carefully observed the disease will 
have inclined toward the opinion that in bad cases it is probable- 
that almost every villus, from the pylorus to the ijeo-csecal valve, 
{has been stripped of its epithelial coating during life. 

" This alteration in the apparatus concerned in the absorption, 
of all nutrient matters from the intestinal canal, and the changes 
accompanying it and preceding it, are probably sufficient to ac- 
count for death by collapse. Most important, therefore, is it to 
ascertain, if possible, the several phenomena of which this denu- 
dation of epithelium is the climax, and the order in which they 
occur. These important organs, the villi, are, in, a very bad case, 
all, or nealy all, left bare, and a very essential part of what con- 
stitutes the absorbing apparatus is completely destroyed. Lt 
only a considerable portion of a villus was denuded, reparation- 
might doubtless occur by new growth from the cells which re- 
mained, but if the villus was entirely stripped, it is more proba- 
ble that it would waste, and its place be at length occupied by a 
new one, which, would grow from, its, base,, than, that epiti ■ ! 



55 

would grow anew from the bare surface. It is probable that the 
extent of this process of denudation determines the severity or 
mildness of the attack. If the great majority of the villi have 
suffered, it is scarcely reasonable to consider recovery more 
probable than it would be after a very extensive burn or scald " 



[We have presented in the preceding pages articles chiefly with reference to the 
causes and paiholoay of cholera Without comment we have their truth and con- 
sistency to ihe judgment of the reader, and devote the remainder of our space to the 
means of prevention and cure.— Compilek.] 

ON THE INTEKNATIONAL SANITAEY CONFERENCE. 

By E. Goodeve, M. B., Surgeon-Major Bengal Army. 

[A Paper read before the Epidemiological Society, December 3, 1866.] 

"Mr. President and Gentlemen. — At the request of your 
Secretary, Mr. Kadcliffe, I have drawn up for submission to the 
Society a sketch of the principal recommendations of the Inter- 
national Sanitary Conference of Constantinople for preventing 
the diffusion of epidemic cholera ; and for the preservation of 
Europe from future invasion of the disease. 

" The Conference has concluded that epidemic cholera origi- 
nates entirely in India, -and never in Europe ; that it is a trans- 
missible disease, following in the wake of man, and not carried 
by the atmosphere to long distances ; that it is spread chiefly by 
the evacuations of choleraic patients ; and that it rages mcst in 
localities which are in bad sanitary conditions. It believes that 
the cholera-poison may adhere to the surface of clothes, walls 
of houses, insides of ships, etc.; and that these may be the 
means of communicating the disease to persons coming within 
their reach. 

'* Starting fi om these principles — the ground-s of which it 
would be impossible to enumerate in the compass of this paper — 
it has based its measures of preservation; aasd asserts that 
Asiatic cholera is to be met by measures of 'restriction of inter- 
course when practicable, by measures ol purification and disin. 
lection, and by measures of hygiene. 

" In the application of these measures the Conference has held 
in view the following objects— viz., to prevent the development 



56 

and spread of cholera in its place of origin, in India itself,, and 
its exportation therefrom; and, in order to preserve Europe, to 
check its advance westward from India ; and to limit its diffu- 
sion in Europe should fresh invasions occur. 

n The Conference has not always gone into very minute de- 
tails ; but has rather contented itself with indicating in a broad 
manner the nature of the measures to be taken, leaving much 
of the minutiae to be settled by the local knowledge of those 
who will apply them. 

" Inverting the order of enumeration above mentioned, I will 
speak of the recommendations in the following order: 

" 1. Of the sanitary measures. 

" 2. Of the measures of purification. 

" 3. Of the measures of restriction. 

' l Sanitary Measures. — The Conference recognizes in the full- 
est manner the absolute importance of attention to the sanitary 
conditions of localities as a means of checking the development 
of cholera epidemics ; and adopts the principle that, against these, 
safety for populations is to be found in the purity of the air, in 
the goodness of their drinking waers, and in the cleanliness of 
the soil on which they live. In accordance with these views, it 
points out the necessity of sufficient space for dwellings, of ample 
room for lodging*, and of free ventilation with air that shall be 
pure. To obtain the latter, it shows that, space and ventilation 
being secured, the purity of the atmosphere depends upoa the 
cleanliness of the surface of the soil, and the non-impregnation 
of its substance with organic decomposing, and especially exeve- 
roentitious, matters. It believes that it is vain to expect that a 
town shall possess a pure atmosphere, one in which the choleraic 
poison has little tendency to multiply; if the soil is loaded with 
these matters, Hence the greatest care should be taken to pre- 
vent its infiltration with such. For this it asks for the abolition 
of all privies, with cesspools or wells, and the substitution for 
them of moveable receptacles, such as earth closets or ' foas.es 
mobiles/ which can be frequently emptied and cleaned, and 
which may be so arranged that faecal matter can not sq.uk iruo 



57 

the soil. The contents should be carried out of the towns. The 
Conference objects to the system of drains or sewers in commu- 
nication with houses, holding that in practice we can not pre- 
vent the diffusion of noxious gases through the houses in 
connection with them, and that in times of cholera, drains may 
spread the disease along a line of houses in communication with 
them j and that, owing to. the porosity and rapid decay of ma- 
sonry work, they readily allow of the impregnation and satura- 
tion of the ground through which they run with decomposing 
organic matters. When used, sewers should not be allowed to 
empty themselves into rivers, and water-closets should never be 
within the houses themselves. Burial-grounds should not be 
permitted within towns. Slaughter-houses and noxious trades 
should be forbidden. Not only should it be an object to prevent 
all human organic or excrementitious matter from penetrating 
the r soil of towns, but every sort of organic refuse should be 
speedil3 T removed, before the atmosphere can become contami- 
nated by their decay above or under the ground. In short, for 
a healthy town, no decomposing organic matter should pene- 
trate its soil or rest upon its surface. As the decomposition of 
organic matter is retarded in a dry soil, towns should always be 
provided with surface, and, where necessary, with subsoi 1 , drain- 
age. As seaports are frequently the first places to receive ar- 
rivals from infected regions, it is obvious that it is of the highest 
importance to place them in healthy states, even more than it 
is for inland towns. The absolute necessity for pure water, and 
the great danger of the use of water contaminated by choleraic 
matters, are pointed out. The liability of contamination of the 
water of *wells or streams near and among which cesspools or 
sewers lie is shown, as well as its unfitness for use under any 
circumstances, and especially during cholera epidemics. It pro- 
poses filtration or boiling for water containing ordinary impuri- 
ties, where none other can be had. 

" The sanitary conditions insisted on by the Conference 
demand for their perfection the exercise of public and private 
hygiene. It may be doubtful how far in the present state of 



58 

society private hygiene will assist in the great work j but all 
that may be called public hygiene in these recommendations 
ma} 1 - certainty be carried out, to the great advantage of the pop- 
ulations concerned. Public hygiene can regulate the width of 
streets, the space for habitations, the space for individuals, the 
direction and termination of sewers and drains, the description 
of privies, the scavengering of towns, and the provision of pure 
water. All these are the prime agents in combating the condi- 
tions in which cholera epidemics flourish ; and if they could be 
faithfully carried out, as they most certainly might be, the short- 
comings of private h}'giene would be of comparatively little 
moment. The Conference has not ignored the difficulties of ob- 
taining the desired state; but it looks f >rward to the time when, 
to quote its own words, ' the minds of all men shall be penetra- 
ted with the truth that most endemic and epidemic diseases owe 
their violence and their spread to the massing together of peo- 
ple, and to the fatal customs prevalent among them. Then all 
will understand that it is in the power of man, at the same time 
that it is his duty, to overcome by his efforts that condition 
which he has created by his ignorance.' These measures are 
not to be taken only when cholera epidemics are near, but 
should be acted on at all times and in all seasons They should 
be made permanent conditions. They may be costty, and they 
are in opposition to the system of sewerage in practice in Eng- 
land. It is probable, however, that reflection will show, and 
time will prove, the much greater security and efficiency of sys- 
tems which seek to maintain the soil free from dangerous mat- 
ters over those which allow them to permeate its sub-tance. I 
will conclude this brief outline by saying that the Conference 
believes that if man is to be preserved from cholera epidemics, 
he must live on a clean soil, drink pure water, and breathe a 
sufficiency of pure air, and that under these conditions cholera 
will rarely rage around him. 

"The sanitary recommendations are not confined to towns, 
but extend to ships, for which the importance of the limitation 
of the number of passengers, free ventilation, and provision of 



59 

pure water free from all taint of choleraic discharges, are fully 
insisted on in the recommendations on naval hygiene and its 
appendix. 

" Measures of Purification. — To destroy the poison adherent 
to surfaces, and to prevent these from becoming sources of dan- 
ger, disinfection and purification of houses, ships, clothing, etc., 
are required, and recommended upon the same principle as they 
are for other contagious diseases ; but, in the opinion of the 
Conference, cholera requires in addition the chemical disinfec- 
tion and destruction of all cholera evacuations, both of con- 
firmed cholera and of diarrhoea. These should always be disin- 
fected separately from common excreta, and never mingled with 
the contents of common privies or drains. They should be 
buried deeply out of harm's way, and where they cannot infect 
drinking-water. The Conference recommends that a general 
disinfection of drains, sewers, privies and cesspools should be 
carried out bj authority throughout the duration of a cholera 
epidemic, and until its extinction; that this disinfection should 
begin in a town immediately that the cases of diarrhasa, in the 
track of an epidemic, show the least tendency to increase; and 
that the use of all common privies should be forbidden diarrheal 
patients during the prevalence of cholera. All linen soiled by 
cholera evacuations, or which have been in use by cholera pa- 
tients, should be plunged immediately into solutions containing 
chloride of zinc or lime, or chlorate of soda, and remain im- 
mersed for twenty-four hours before washing, which ought to 
be thoroughly done, and combined with boiling of sucn articles; 
and that all articles which can not be so treated, such as bed. 
ding and thick materials, should be burnt. The temporary 
abandonment of infected houses, barracks, and dwellings of all 
kinds, and their purification by free ventilation, sprinkling or 
washing the walls with solutions of chloride of lime or carbolic 
acid, and by the diffusion of sulphurous or nitrous acid gas, or 
chlorine gas, and whitewashing, should invariably be carried 
out; and several da}~s, at least eight, should be allowed to elapse 
before their reoccupation. Measures of similar character ar® 
recommended for contaminated ships. 



60 

<x The purifying agents most relied on are chloride of zinc, 
sulphate of iron, carbolic acid, sulphurous acid and nitrous acid 
gases, free ventilation, and a temperature of 212° to 250° Fah- 
renheit, for articles that can be submitted to it without damage. 
Certain kinds of goods, such as old stuffs, rags, skins, etc., 
should also be disinfected It is not proposed to submit general 
merchandise to disinfection. The bales of goods, however, have 
to be landed when a ship is to be disinfected. 

u The opinion of the Conference on measures of disinfection 
and purification is expressed in the following resolution : ' That 
measures of disinfection, applied to cholera, on a well-arranged 
plan, and with perseverance, offer themselves as powerful auxil- 
iaries — 1st, for diminishing the liability of a locality ihreatened 
with cholera ; 2d, for destro3 T ing the germ of the disease ; and 
3d, for limiting, in certain iavorable circumstances, the spread 
of the epidemic/ 

"Measures of Restriction. — A belief in the propagation of chol- 
era by human intercourse naturally leads to recommendations 
of measures for limiting such intercourse, and these have been 
proposed by the Conference. It considers restriction as regards 
cordons sanitaires, isolation of the sick, complete interruption of 
communication between infected and healthy places, and the 
modified interruption known as quarantine. Eestriction of in- 
tercourse has to be considered as regards land and sea, and, as 
applied to ships and passengers, demands the machinery of bills 
of health, inspection previous to embarkation at infected ports, 
lazarettos, and the means of purification of contaminated or 
suspected objects. 

" With regard to sanitary cordons, the Conference concludes 
that these, established in the midst of numerous and dense pop- 
ulations, are uncertain in effect; but that, on the other hand, 
employed over limited districts, or in countries in which the 
population is thinly spread, as in certain countries in Asia, cor- 
dons are of great use against the extension of the disease. 

" With regard to iso^tion, it believes that when it can be ap- 
plied to the first cases which mark the beginning of an epidemic, 



61 

it is a measure of prudence which no country desirous of its own 
safety should neglect. 

" With regard to the total interruption of communication, it 
recognizes this as efficacious, if practicable, but admits the im- 
possibility of carrying it out in general; and contents itself with 
stating that interruption of communication is the best method 
of isolating cholera centres, and that in consequence it should 
be applied in all eases in which circumstances permit of its effi- 
cient performance, but that this measure — only applicable over 
limited districts — becomes impracticable and inefficacious when 
an epidemic is spread over a large space. 

" On the question of checking emigration from infected towns 
to surrounding places, the Conference recognizes the great evil 
of the flight of masses of people from the seats of epidemics, and 
its influence in spreading the disease. It thinks that, without 
preventing persons from moving from infected towns, it would 
be well if they could be restricted to limited areas around thes^ 
diseased localities. With regard to people moving away by sea, 
it would limit the number of passengers in each ship, and sub- 
mit them to medical inspection and their goods to disinfection 
before embarkation. 

" Quarantine is to be considered in its sea and land aspects, 
Land quarantines, from what has been already remarked, have 
not been often applicable; but in cases of caravans, troops and 
masses of emigrants, it may be found occasionally very valuable. 
Maritime quarantine, however, on account of the greater facility 
for maintaining it, is considered to be much more likely to be 
efficient than that on land, and the conclusion was adopted that 
these quarantines, established on a rational basis, and in con- 
formity with the progress of science, may serve as effectual bar- 
riers to the invasion of cholera. 

M The quarantines recommended are of two kinds— the quaran- 
tine of observation and strict quarantine. 

" 1 Quarantine of observation consists in keeping separately 
and under surveillance, a ship, its passengers and crew, for a 
period of some days from the time of the admission on board of 



m 

the health guardians, the time to be regulated by the local sani & 
tary authorities. It does not require the disembarkation of the* 
passengers, nor the discharge of goods or merchandise, unless 
the} be injured or in decomposition. It enjoins free ventilation 
of the ship and general measures of hygiene, but not its disin- 
fection. It may be gone through at any port in which a sani- 
tary establishment exists. In some special cases the passengers 
may be disembarked and landed at the lazaretto. It is applied 
to ships in good sanitary condition, which have not suffered 
from cholera. 

" 2. Strict quarantine is the isolation, for a fixed time, of the 
ship and persons, with disinfection of all that may contain the 
seeds of the disease. It demands the discharge of all the mer- 
chandise into the disinfecting houses, the disinfection of certain 
articles or goods, and the landing of passengers at a lazaretto. 
It is applied, 1, to ships from an intected port with a foul bill of 
health, with certain exceptions ; 2, to ships which have had 
cases of cholera on board during the voyage, although they may 
have a clean bill of health. Strict quarantine begins with ships 
in ballast when the quarantine officers commence their watch 
on board; for other ships, after landing of the goods; for per- 
sons, immediately that they enter the lazaretto. 

° Thus, according to the Conference, quarantine of observa- 
tion is a term of probation, of simple watching; while strict 
quarantine consists in the landing of passengers at a lazaretto, 
with the use of disinfection and of every measure of precaution 
that can be applied to arrivals from infected ports. 

" Time of separation of suspected persons. — The Conference 
has recommended, by a majority, the period of ten days as the 
time of separation or isolation of arrivals from infected places, 
both for land and sea quarantines. This term has been fixed 
upon because, while it seems likely to accomplish all that we 
expected from quarantine, it will not be so onerous to the inter- 
ests of commerce as the periods of sequestration adopted by 
some nations during the present epidemic The Conference, in 



m 

this matter has endeavored to regard both the demands of eotft* 
meree and the interests of science. 

" The Conference has judged that, India being the place of 
origin of cholera, it would be of great moment to attack the dis~- 
ease in India itself, to prevent its exportation therefrom, and to 
check its progress westward by restrictive measures ; believing 
that these will be all the more efficacious the nearer they are 
applied to the sources of the disease. Cholera may reach Europe 
by sea, through the Persian Gulf and by the Eed Sea; by land, 
through Central Asia, Persia, Syria and Eussia. 

"It would be very desirable that w T e should know something 
accurate of the mode of origin of cholera in India, and this 
would probably assist us to extinguish the disease in its cradle, 
or in the parts of India in which it is endemic. It is very possi- 
ble that the endemic centres are the starting-points of the differ- 
ent Indian epidemics, and that as regards these, the endemic 
centres are to the greater pari of India much as India is to the 
rest of the world. If we could extinguish cholera in the locali- 
ties where it is permanent, the Indian epidemics would, perhaps, 
not arise. This important point in the etiology of cholera like 
that of many other diseases, is unknown. The manifest advan- 
tage of such knowledge has induced the Conference to appeal to 
the British Government to institute inquiries into the etiology 
of the disease, in the hope of thus obtaining information of great 
value in prophylaxis. Upon the question of the origin of chol- 
era in places in which it is endemic or permanent, I wish to ex- 
press my great doubts whether the disease has any local terres- 
trial origin ; that there is any local choleraic miasm proceeding 
from the soil as a natural product. It appears to me, and my 
able colleague in the Commission, Dr. Dickson, that the fact of 
cholera being a transmissible disease is sufficient to account for 
its permanence in certain favoring situations. A transmissible 
disease in conditions favorable to its multiplication — i. e., in bad 
sanitary conditions— may maintain itself permanently in a lo- 
cality. If this is the case, we may dispense with ideas of spon- 
taneous generation of the disease, or with the somewhat favorite 



64 

theory of a miasm issuing from the soil of the Delta of the 
Ganges. The mode in which cholera has maintained itself, per- 
manently in places beyond the Delta of the Ganges, as in Bom- 
bay, for instance, from which it has not been absent a single 
month during the last twenty years, shows its capability of as- 
suming an endemic form in situations which can hardly be called 
its birthplace ; and if it can do so in Bombay, why not in the 
towns in the valley of the Ganges, where bad sanitary conditions 
are rife enough, and where favoring meteorological conditions 
ma} T also be found? It may be, then, that what may be called 
the endemicity of cholera is little more than a prolonged epi- 
demic. It would be a fortunate thing for humanity if researches 
could establish this. It would be far more easy to extinguish 
the disease by removing the man-created favoring and remedial 
conditions of multiplication than it would be to alter the ph} T si- 
cal conditions of the soil of the Delta of the Ganges. The first 
is possible with well-directed and continuous effort ) the latter 
may be fairly considered impracticable. 

" The Conference thinks that the Congress of Hindoo pilgrims 
at the numerous shrines and fairs readily accounts for much of 
the propagation and diffusion of cholera in India; and it recom- 
mends the general adoption of measures of hygiene, and of re- 
striction upon the pilgrims returning home, already in use in 
some localities. It also asks the Government of India to con- 
tinue in the path of sanitary reform which it has alreadj' ener- 
getically commenced, and looks forward to great advantages 
therefrom, in diminishing, if not extinguishing, cholera. It sub- 
mits that measures of restriction, where practicable, might, 
pending the full realization of sanitary measures, assist in 
checking the propagation of the disease," 



65 

INTERNATIONAL CONFERENCE ON CHOLERA. 

[From Lancet, December 8th, I860.] 

"The great preventive scheme of the Conference on Cholera 
that met at Constantinople," remarked Dr. Jenner, in his Inau- 
gural Address as President of the Epidemiological Society, " wa3 
strict quarantine, especially between India and Europe — a most 
vexatious, most costly, and most impracticable scheme." 

° Neither practicable nor rational," was the terse and forcible 
expression with which Dr. Farr ended the discussion and sum- 
med up his opinion of the scheme at the meeting of the Epidem- 
iological Society on Monday last. In terms not less strong did 
Dr. tylilroy and other members characterize the infeasibility of 
the recommendations of the Conference for the protection of 
Europe from future invasions of cholera. And it would appear 
from the clear and comprehensive account of the proceedings of 
the Conference submitted by Dr. E. Goodeve to the Society, and 
which formed the basis of the discussion, that the British Medi- 
cal Commissioners in the main dissented from these recommen- 
dations. 

The objections urged against the great scheme of quarantine 
suggested by the Conference for the purpose of raising a barrier 
against the transmission of cholera from India to Europe (rest- 
ing these solely upon its inherent worth) are very cogent. Fore- 
most is the question of expense. Dr. Jenner holds that, so far 
as this country is concerned, its hygienic condition might be so 
greatly improved, at a much less cost, as to prevent the spread 
of cholera, even were its zymotic element constantly among us. 
And he further urges, as giving additional weight to this consid- 
eration, that the improvement in our hygienic condition to such 
a degree would not only prevent the spread of cholera, but di- 
minish the mortality from almost every other preventable dis- 
ease. This argument, however, applies equally to every Euro- 
pean country, and with scarcely less force to the Delta of the 
Nile, and the sacred land of Mohammedanism — the Hedjaz. It 
may be extended also, almost unweakened, to the focus of epi- 
demic cholera, British India. This has been clearly shown by 



66 

the effect, of recent sanitary measures there The dancer to tho 
public health arising from the Hindoo religious festivals — the 
chief hot-beds of cholera — may be obviated by a systematic san- 
itary regulation of the places where they are held, and of the 
crowds of devotees who attend them. Conjeveram, the scene 
of a celebrated festival; and long a persistent centre of choleraic 
infection of the surrounding country from the ebb and flow of 
vast numbers of pilgrims, has, under the energetic measures of 
the Madras Presidency Sanitary Commission, been purified, and 
subjected to strict sanitary rule, with the happiest results. Two, 
if not three or more, of the festivals have already passed without 
an explosion of the dreadful epidemic. This fact, the impor- 
tance of which, in its bearing upon Indian sanitation and the 
restriction of cholera, was urged in the discussion of Monday 
night last by Dr. A. P. Stewart, does not stand alone. Dr. E. 
Goodeve at the same time supplied a still more striking exempli- 
fication of the efficacy of hygienic measures in India. There 
are, he stated, in the Bombay Presidency, ninety-four shrines to 
which pilgrimages are made. In the past year, for the first time, 
these shrines, and the devotees frequenting them, were subjected 
to sanitary control. The result was remarkable. At only two 
of the shrines did cholera appear, although the disease was far 
from being inactive among the native population of the Presi^ 
dency. 

Dr. Goodeve holds, and in this belief he is supported by his 
brother Commissioner at the Conference, Dr. E. Dickson, that 
the persistence of cholera in India is owing, not to any pecu- 
liarity of the soil, but to the continued transmission of the dis- 
ease under unhealthy conditions singularly favorable to such 
transmission, engendered by man, and admitting of remedy. 
ITe believes that this theory of the permanent repetition of the 
disease is most in accordance with the facts of its prevalence as 
observed at the present day; and that it offers less difficulty to 
acceptance, and is more fruitful in practical consequences th:\« 
the vague theories of spontaneous generation. 



"&N DISINFECTION, WITH ESPECIAL KEFE&ENCE TO CHOLERA, 

By Dr. Max Pettenkofer. 
[Schmidt's Jahrfeuecher, 1886, Bandcxxxi.] 

The following is an abstract of a paper published in the Zeits 
thrift f. Biolo-gie, 1866 : 

l( The excretions of cholera patients are, in their recent state) 
generally either neutral or feebly alkaline; but after the lapse of 
a short time they become decidedly alkaline. All means which 
prevent the excretions from becoming alkaline change the ordi* 
nary course of their decomposition, and all disinfectants against 
cholera are to be valued accordingly as they are able to prevent 
the commencement of ammoniacal decomposition in the urine 
and faeces. The agents that fulfill this purpose are, metallic 
salts, mineral acids and carbolic acid, by means : of which urine 
and faeces may be preserved for many months in an acid condi-- 
tion. Among the metallic salts, the sulphate of iron deserves the 
preference, both on account cf its activity for the object to be 
attained, and also on account of its cheapness and of its ready 
accessibility in any quantity. The quantity required will de- 
pend upon whether the excretions to be disinfected are still re- 
Cent or have already undergone ammoniacal change. For the 
disinfection of cesspools, where change has already taken place) 
the salt must be added in concentrated solution until the odor of 
ammonia and of sulphuretted hydrogen is completely removed, 
or until the contents of the pit, after stirring, have an acid re- 
action. For recent excrement, the average quantity required 
for each person will be about an ounce daily. The most certain 
method is to have the excrement disinfected before it is allowed 
to pass away into the pit or sewer. It does not lose its pro- 
clivity to every kind of change, nor all foetor ; but the ammoni- 
acal change will with certainty be delayed for months by the 
addition of the above-mentioned quantity of sulphate of iron. 
The excrement may therefore be conveyed away from the vicm* 
ity of human dwellings while still in an acid state. The fcetor 
can not be removed by any means, and can only be concealed 
foy stronger penetrating odors. 



et The prevention of ammoniacal change in excrement tn&f ^tsa 
by effected by mineral acids, as the sulphuric and hydrochloric, 
and also by carbolic acid ) but the practical applicability of these 
agents is very limited when compared to that of sulphate of iron. 
If excrement already ammoniacal be treated with sulphuric or 
hydrochloric acid, much carbonic acid and sulphuretted hy- 
drogen will be developed — substances the development of which 
should be avoided with all possible care. The mineral acids, 
moreover, act not only upon iron and zinc, but energetically 
upon the mortar of the pit, and would be neutralized by it- 
Sulphate of iron, on the contrary, prevents the formation of 
sulphuretted hydrogen, and affects neither iron, zinc, nor mor- 
tar, nor is neutralized by them. 

H Another agent which possesses some, if only a limited, ap- 
plicability as a disinfectant, is sulphurous acid This is certainly 
effectual in preventing the development of sulphuretted hydro- 
gen, which it decomposes to form sulphur and water. Since, 
however, it is not alone in the destruction of sulphuretted^ hydro- 
gen, but far more in the establishment of an acid reaction, that 
we seek the essentials of disinfection, the use of sulphuric acid 
alone is attended by the same disadvantages as the use of other 
mineral acids. In the combined form, as a sulphite, the sul- 
phurous acid is wholly inoperative, and can not in the least delay 
the commencement of alkaline reaction. It even seems to con_ 
duce to this reaction ; for urine treated with sulphite of soda 
containing some excess of acid, then neutralized by carbonate 
of soda, then feebly acidified by acetic acid, will become alkaline 
some days sooner than the same urine if left without admixture. 
The presence of a sulphite can, therefore, never be regarded as 
an impediment to the ammoniacal decomposition of urine and 
faeces. It is only the free sulphurous acid that possesses this 
property, and certainly not in a greater degree than any other 
free mineral acid. But as sulphurous acid is easily obtained in a 
gaseous form (by burning sulphur, or 1 by treating sulphites with 
concentrated sulphuric or hydrochloric acid), it must be retained 
upon the list of useful disinfectants, especially for places thai 



69 

ean not 'be reached by fluid agents, such as inaccessible sewers. 
For the disinfection of linen and clothes, it is also at least as 
useful as chloride of lime, without being so destructive to the 
textures. 

"The carbolic acid, when used in very small quantity, pre- 
vents the ammoniacal decomposition. Properly diluted, it 
scarcely acts at all upon iron or zinc, and very little upon mor- 
tar ) and it covers the foetor of excrement completely, whilst its 
own odor, when diluted, is very bearable. It is not, however, 
readily obtainable in large quantities ; it is dear, and inferior to 
sulphate of iron in other respects ; nevertheless, it is a good and 
useful disinfectant. One part of carbolic acid should be dis- 
solved in twenty parts of water ; and a quarter of a litre of this 
solution will be sufficient for the daily excreta of four persons, 
and will keep them acid until they can be conveyed a way. J 

41 In order that disinfection may be of any practical utility, it 
must be thoroughly carried out. Partial disinfection is of no 
use whatever. It is merely lost labor to acidify the excreta day 
by day, and to let them pass into a pit containing matters al- 
ready ammoniacal ; and it is only when the pit and its contents 
have been completely disinfected that the disinfection of single 
evacuations can fee of advantage. 

" The use of chloride of lime has been condemned by Dr. Pet- 
tenkofer as irrational, since it is an alkaline agent. It would be 
paradoxical to combine it with sulphate of iron ; for each neu- 
tralizing the other, no disinfection would be eifected at all, un- 
less one of the two was in greatly preponderating quantity. It 
might also occur that a cesspool, already rendered acid by sul- 
phate of iron, might receive so much chloride of lime, as to re- 
store its alkalinity, so that the ammoniacal decomposition would 
be promoted. 

" Since disinfection is manifestly a prophylactic measure, it is 
obvious that.it ought not to be delayed until cholera has shown 
itself. When once an undoubted case of cholera has occurred 
in any house, disinfection is of little value there as regards the 
inmates, who have already been exposed to the poison ; so that 



70 

It will depend upon individual predisposition, and- the duration 
of the incubatory stage, whether more of them will be attacked. 
Disinfection has then its only value as regards the future inter- 
course that other persons may have with the place, and it is use- 
less for those who have already been there, and who, as well as 
the inmates, may be infected. Visitors may even carry away 
germs to their own houses before they show any clear symp- 
toms of disease themselves ; and these germs may be developed 
or not, according to local and individual predisposition. In all 
past epidemics of cholera, disinfection has only been commenced 
after the outbreak of the disease, except at the cholera hospitals 
of Altenburg and of the town of Zwickau, when the prophylactic 
disinfection with sulphate of iron was generally, and in good 
time, carried out ; and where, also, especially in Zwickau, the 
consequences can scarcely be denied. 

"It must be admitted that the times for commencing and for 
leaving off disinfection have not yet been certainly determined;, 
but according to past experience, the level of the surface-water 
affords a valuable criterion. It seems that the time when the 
surface-water recedes from an unusually high level is to be con- 
sidered as the period of danger. 

'* [For the disinfection of air, Dr. Badstiibner (Berlin Klin, 
Wochenschr.y 1866) recommends the permanganate of potash 
(Condy's fluid), and especially for sick rooms. Berenger-Ferand 
(Gaz, de Paris, 1866) considers the same agent to be the best 
disinfectant of cholera. Both writers think it preferable to the 
sulphate of iron, except when its price is a difficulty in the way. 
Badstiibner also cites cases in which it was of great value in 
destroying the fcetor of sputse. 

" Dr. Th. Clemens, of Frankfort-on-the-Maine (Beutschs Klinik, 
1865-6; Schmidt's Jahrbucher, 1866), has observed the immunity 
ftom. cholera of coppersmiths. Hence he reeommends, as a 
cholera disinfectant, a spirit of chlorate of copper, and uses the 
same preparation, both internally and upon the skin, as an 
actual preservative. 

"His formula., is as follows:. Liq. cupri. perchl.orati conce,n.t^ 



71 

3ij.; ehlorof , 3i.; spir. vini, gvj. As a preservative; two or three 
drops of this compound, twice a day ; and he also orders it to 
be rubbed into the abdomen. As a disinfectant, the same fluid 
is to be put into a common glass spirit-lamp, and the wick 
lighted. A vapor of chlorate of copper is formed, which in five 
minutes will pervade a chamber of five thousand cubic feet so 
completely, that all objects contained therein will be impreg- 
nated. In this way both the air and all matters will be quickly, 
and without danger, disinfected. Dr. Clemens holds the facility 
with which this can be done as a great advantage ; and he has 
never seen, even in children, the slightest injurious action from 
the vapor.] " 

[From Ranking' s Abstract, Vol. xliv.] 

RULES FOE THE GUIDANCE OF SANITARY AUTHORITIES, 
PRACTITIONERS, AND THE PUBLIC DURING: THE PREVA- 
LENCE OF EPIDEMIC CHOLERA. 

By the Professors Dr. W. Gkiesinger, Dr. Max von Pettenkofer, and Dr. C. A. 

Wtjnderlich. 

[The following instructions respecting the restraint and prevention of epidemic 
cholera, drawn up by three of the most distinguished German physicians, each of 
Whom writes with special authority on the subject, and representing the most advanced 
teachings of the day, are so full of instruction and interest, that we have translated 
them without curtailment. — Ed.] 

Introduction. 

The cholera, this year, has made its appearance early. How 
far it may extend is uncertain. The dryness of the year 1865, 
of the past winter, and of the present spring, renders doubtful 
any great epidemic extension of the disease in many parts of 
Germany. Yst we are far from knowing all the conditions of 
the epidemic sufficiently to have any certainty in this respect. 
The movements of troops in Germany, when once a few centres 
of the disease have been established, may cause its rapid spread 
in districts predisposed to it ; and, even if we should escape 
during the present summer, who can tell when this destructive 
malady may again threaten us? 

With regard to the spread of cholera, and the causes of its 
epidemic prevalence, science is in possession of certain estab- 
lished positions, resting upon careful examination of sufficient 



72 

data. These positions are known to those medical practitioners 
who have closely devoted themselves to the subject; but many 
know them only imperfectly, or, by reason of unfounded doubts, 
do not hold them with full conviction. By the public these 
positions are almost entirely unknown; although they afford 
the only basis for any effectual measures of prevention, and 
although they are very simple and intelligible to every one. 
When cholera approaches a place, we commonly see among the 
inhabitants only a bewildered terror, and a grasping at ex- 
pedients that are useless, or even hurtful, although vaunted by 
greed ; instead of a firm resolution on the part of each one to 
combat the common enemy by a consistent application of the 
means that science and experience point out as efficacious, and* 
by which every one can best protect his own threatened life. 
The sanitary authorities themselves are frequently uncertain 
about the utility or the necessity of the most important 
measures, such as quarantine, seclusion, and disinfection. It 
need therefore be no matter for surprise that reall}^ effectual 
measures are often neglected, or, on the contrary, that wholly 
useless or absurb procedures should be put in practice. In this 
spring, for instance, in one of the small epidemics, we have seen 
the air of the streets fumigated by burning juniperberries ! 

Under these circumstances it seemed to us advisable to put 
together, in a concise form, for the use of sanitary authorities, 
of the medical profession, and of the public, those principles 
with regard to the spread of cholera which are firmly established. 
on a scientific basis, and on which the chief preventive measures 
are themselves founded ; and to show both the scientific grounds 
of such measures, and the proper methods of carrying them into 
practice. W e have done this in the following pages; and we 
confidently hope that our communication, will receive attention, 
and that the calamities which cholera epidemics entail upon. 
human society may be diminished by the consideration and ob- 
servance of what we have here laid down. 

With regard to disinfection, we have furnished practitioners 
and authorities with a principle of practical application, which. 



73 

was, indeed, the basis of many of the methods formerly in use, 
but which had not previously been stated with sufficient clear- 
ness and precision. This principle seems to us to flow 
immediately from known and proved facts; and from its com- 
plete expression we may expect a final determination of a well- 
defined question, and hence a step in our knowledge of, and our 
opposition to, cholera. 

For the comprehension of cholera, a right observation of the 
epidemics is the first necessity. We, therefore, thought it not 
superfluous to state, in the second part of our tract, the essential 
points to which useful observations must be directed. This part 
is addressed only to the medical profession and to the sanitary 
authorities. It states briefly the matters about which informa- 
tion is requited by science, in order that the occurrences during 
an epidemic may be correctly stated, and rendered fruitful for 
the prevention or suppression of future visitations. It is im- 
possible that all points of this programmo of observation should 
be equally well carried out in all places It is better that one 
part of it should be carried out, earnestly and consistently, than 
that all should be attempted, with insufficient means and divided 
force. In large or moderately large states, where chiefly there 
will be opportunities for a complete fulfillment of the pro- 
gramme, a division of labor in accordance with the different 
aspects of the facts is essential. 

We hope that our little tract may conduce to identity of 
management and of observation on the part of governments and 
sanitary authorities. 

A. MEASUEES AGAINST THE EXTENSION OF CHOLEEA. 

It is the fact that cholera — that is, its specific cause, its germ 
— is disseminated through the personal intercommunication of 
mankind. According to observation hitherto, we may assume 
that this germ is contained chiefly, probably exclusively, in the 
intestinal evacuations of persons coming from places infected by 
cholera, and suffering from diarrhoea or cholera themselves. 
Whether persons not so suffering, but feeling perfectly well, and 



74 

only coming from infected localities, are likewise capable of 
disseminating the germ, can, in tho present state of knowledge, 
neither be affirmed nor denied with certainty. 

Notwithstanding active intercommunication, and a presumed 
abundant dissemination of cholera germs, there are many times 
and places in which epidemics of the disease do not occur. We 
must therefore assume that the dissemination of the germ must 
coincide with the presence of certain auxiliary causes — tem- 
porary, local, or personal — in order that an epidemic may be 
produced. It can not be doubted that the most important of 
these auxiliary causes must be due to the qualities of the soil, 
and to the personal condition of individuals. Kence the meas- 
ures for preventing the spread of cholera must be founded upon 
a consideration of three essential points : 1. Upon the cholera 
germ in the evacuations ; 2. Upon the local peculiarities of soil, 
especially in the subsoil of dwelling places; 3. Upon the con- 
dition, that is, the state of nutrition and the manner of life of 
the people. 

DISINFECTION. 

Section First. — The Principle of Disinfection. 

The evacuations containing the cholera germ can be so 
altered by chemical agencies as to lose their injurious action. 

The fresh evacuations of cholera patients, or of persona 
coming from places where cholera prevails, do not exert a 
poisonous (cholera producing) action ; but differ, in this respect, 
from what is seen in other infectious diseases, such as small- 
pox, in which the sufferers communicate a maturo and active 
infectious material to others It is only after the occurrence of 
a certain decomposition and change, which very probably takes 
place external to the organism, that the cholera evacuations 
acquire the property of producing the disease in healthy 
persons ; and it is only when the already mentioned predis- 
posing or auxiliary causes are in operation that an epidemtc 
extension of the disease can be occasioned. The cholera germ, 
whether we conceive it to be a poison, a ferment, or a cell, 



75 

mud '.here fore be an organic material, for the development of 
which certain external conditions are required. 

At present no practicably applicable means is known by 
which either all the organic components of urine and faeces may 
be instantaneously destroyed, or by which changes in them 
external to the organism may be prevented, so as to preserve 
them in their fresh condition. There is, however, reason to 
believe that this is not necessary for the destruction of the 
cholera germ. It appears to be sufficient so far as to modify 
the decomposition of the excreta, by the admixture of certain 
substances, that the conditions under which the cholera germ is 
commonly developed may be retarded. Although we are 
unacquainted with the exact nature of the cholera germ, and 
with the changes that it undergoes before it becomes active in 
the causation of disease, yet we are able, with great probabilitj* 
of being in the right, to lay hold of certain chemical indications, 
with respect to disinfection, in the fluids that convey the cholera 
germ, both before its infectious action begins and after it has 
acquired this peculiarity. 

Every mixture of recent urine and feeces acquires, after a few 
days, an alkaline reaction ; the result of a spontaneous decompo- 
sition that produces carbonate of ammonia. The evacuations of 
diarrhoea are often alkaline from the first; and the evacuations 
of cholera are alkaline as a rule. Experience has long since 
shown, and chemistry teaches, that a great influence is exerted 
upon the occurrence of certain changes and decompositions in 
organic matter that is moist, or suspended or dissolved in water, 
by the reaction of the fluid portion, so that certain changes 
occur chiefly in acid, others in alkaline, others again in neutral 
fluid; and for many the one or the other reaction is even an 
indispensable condition. 

With regard to the cholera germ, or cholera poison, it is a 
matter of fact that its development is in no way hindered by the 
presence of even a very considerable quantity of carbonate of 
ammonia or sulphide of ammonium (substances with an alkaline 
reaction); but, on the contrary, the facts show wit& great 



76 

■uniformity that the germ, once introduced, everywhere multi- 
plies and increases the more abundantly, the more extensive and 
potent is the action of the constantly alkaline contents of cess- 
pools upon the soil and the atmosphere of a house. 

It must therefore be considered extremely probable that the 
alkaline reaction of excrementitious fluid, from the presence of 
carbonate of ammonia, is among the most necessary or essential 
•conditions for the development of the germ or poison of cholera. 
Upon this ground it may be anticipated that the retardation of 
the occurrence of alkaline reaction, or, where it has occurred 
already, its complete neutralization until a decided acid re- 
action is produced, may prevent the development of the noxious 
germ. 

Second. — Enumeration of the Principal Disinfectants. 

In order to fulfill the above mentioned disinfection, several 
agents maybe employed; and from among these we have to 
select such as can be procured easily in sufficient quantity, and 
such as exert no hurtful influence upon mankind or upon dwell- 
ings. 

All metallic salts that have an acid reaction, and are soluble 
in water, may be used as cholera disinfectants. Among these 
the sulphate of iron is the cheapest, the most common, and the 
most easily procurable in bulk. 

Chloride of manganese, a product obtained in the manufacture 
of chloride of lime, is of equal value with the sulphate of iron, if 
it be first' freed from hydrochloric acid, by neutralization with 
metallic iron, or by other methods of removal. In the vicinity 
of chemical works, the chloride of manganese is commonly 
•cheaper than an equivalent quantity of sulphate of iron ; but the 
whole quantity produced is too small to be generally employed 
as a disinfectant. 

A similar purpose is fulfilled by the use of the soluble salts of 
zinc, the sulphate and chloride. These are more expensive 
than sulphate of iron j but do not produce rust stains when 
-scattered about. 



The power of preserving recent excreta in an acid condition 
is possessed also by many other substances; among which 
carbolic acid (hydrate of phenyl, Frankfort creosote) demand© 
prominent mention. It can be made from coal in great quantity ;■ 
and, since, for this purpose, purity is not required, at a cheap 
rate. Unfortunately, it is not now to be procured in sufficient 
hulk for general use as a disinfectant; and, moreover, it is use- 
less without the simultaneous application of a metallic salt 
(sulphate of iron), in cases where it is required to restore the 
acidity of excreta that have already become alkaline. The pre- 
serving power of the metallic salts may, however, be very 
greatly increased by an extremely small addition of carbolic 
acid. A solution of carbolic acid may be considered equivalent 
to crude pyrcligneous acid. 

The substances already mentioned are all employed in a 
liquid form, dissolved in water ; but there are cases in which a 
gaseous disinfectant is required, as, for example, when places 
are to be disinfected (such as irregular cesspools, inaccessible 
drains and sewers) which offer insurmountable obstacles to a 
complete saturation with fluid. In such cases we should employ 
volatile or gaseous acids, among which the sulphurous acid is 
chiefly to be recommended. It may be obtained by the com- 
bustion of sulphur or of sulphur matches, or by treating sulphites 
with concentrated sulphuric or hydrochloric acid. 

The agents already enumerated act in accordance with their 
chemical qualities, by retarding or preventing the alkalinity of 
the excreta. Besides them there is yet another substance that 
has been largely used as a disinfectant-^namely, chloride of 
lime. There are no certain facts known with regard to its 
action ; and although it would perhaps be erroneous to pronouce 
it wholly inoperative, it would certainly not be wise to place, in 
the sam© category with the preceding acid reagents, a substance 
of an entirely different nature, that by its alkaline reaction could 
only interfere with their efficiency, and that moreover cannot 
be obtained in quantities, and at a price to render it available as 
a general disinfectant. 



Third. — The Qumitities in which Disinfectants should bk 

employed. 

The question as to the quantity of any disinfectant that should 
fee employed may be answered by saying that the end sought 
is attained when the excreta, and all that is mixed with them> 
possess a decided acid reaction ; and retain it until they can be 
moved away from the vicinity of human dwellings. 

We may assume that twenty-five grammes of sulphate 
of iron (or an equivalent quantity of the salts of zinc or man- 
ganese) dissolved in water, would, on an average, be a sufficient 
daily quantity for each person. This calculation supposes that 
the population is made up of persons of all ages in the ordinary 
proportions; and that the recent excreta are not added to old 
collections, already in a state of alkaline decomposition. Such 
collections should either be entirely removed at the beginning of 
the disinfection ; or, what is more simple, should be so liberally 
treated with the acid agent, as to completely destroy their 
alkalinity. 

The quantity of twenty-five grammes is taken as an average 
loradultcs arid children, for the diseased and for the healthy. A 
mixture of recent urine and faeces from a healthy person is 
almost always acid ; but a similar mixture, from a patient 
suffering from diarrhoea, is very often alkaline when voided. 

When such a mixture of excretra is actually acid, it can be 
kept so by a very small addition of carbolic acid. Where there 
is the opportunity of employing this agent, it is greatly to be 
recommended; since it not only perfectly fulfills the purpose of 
a disinfectant, but also represses more than anything else the 
foetor of the excretions. Three grammes of pure carbolic acid) 
or four grammes Of an acid not perfectly pure, as it is first 
separated from the crude carbolate of soda, dissolved in 100 
grammes of water by agitation, will suffice for each person 
daily; supposing that the excreta are already acid. 



n 

fourth. — The Objects to be Disinfected. 

The disinfection must have reference, first to the excreta, arid 
then to all contrivances or apparatus for holding, collecting, of 
conve} T ing them ; and generally to everything in which excre- 
ment has been contained. The excreta, whether urine, faeces, 
or matters vomited, should be discharged by the patient, when 
possible, into vessels already containing the disinfectant. Not 
only the evacuations themselves, and all utensils, buckets, 
water-closetSj cesspools, sewers and pipes that may have con- 
tained them should be disinfected, but also soiled linen, clothing, 
or wooden floors on which excreta may have been spilt. The 
intestinal contents of cholera corpses, and everything soiled by 
them, must be treated in the same manner. 

The medical advisers of the different local authorities should 
make such suggestions, that the rules above laid down may be 
adapted to the special conditions of each place. 

For the disinfection of soiled linen and clothing, and also of 
wooden floors, the chloride of lime has heretofore been generally 
employed. With respect to it we can only refer to what has 
been said already. Sulphate of iron, and chloride of manganese 
containing iron would injure clothing and floors, by covering 
them with rust stains. Solutions of carbolic acid in water, or 
of the salts of zinc, have not this disadvantage. The carbolic 
acid produces great annoyance by its very persistent odor, and 
when applied to floors renders them extremely unpleasant for a 
long time \ so that for linen and such matters watery solutions 
of sulphurous acid, or of sulphate or chloride of zinc, are to be 
* preferred. 

Above all things the public should be apprised of the important 
truth that the universal experience of practitioners and nurses 
proves that the recent evacuations, even in the most acute form 
of Asiatic cholera, are not sources of danger; and that there is 
the less to be feared the more speedily the proper steps for dis- 
infection and cleanliness are taken. 

It is self evident that the most complete possible removal of 
all organic remains and foul substances from the vicinity of 



80 

human dwellings, and the destruction of all worthless or sus- 
picious refuse, should be strictly enforced; but never without a 
preceding thorough disinfection. 

Fifth. — When the Disinfection should be commenced. 

It is an important question where and when disinfection 
should be commenced. In every epidemic of cholera it has 
been observed that many places, notwithstanding constant com- 
munication with other places smitten by the disease, have re- 
mained free, or at least have suffered no epidemic visitation; 
and also that places attacked in certain years have escaped in 
others ; although no change has occurred in the intercourse or 
manner of life of their inhabitants. As reasons for these im- 
portant phenomena it has hitherto only been suggested that 
peculiarities of soil may act as local, and variations of the earth's 
moisture as temporary causes of exemption. Upon this question 
the most important points will be referred to in the second 
section. 

The determination of the question, what places, or parts of 
places, or neighborhoods, and what periods of time, are most 
favorable to the development of a cholera epidemic, must de- 
pend upon a careful local observation and research, such as 
hitherto could only be carried out long and closely enough in 
the smallest districts. 

When the introduction of the disease and its epidemic de* 
velopment in any place is to be feared, we ought not to wait 
with our disinfectants until the epidemic character of the out- 
break has been shown in several houses and cases. The disin- 
fectant should not, as has often formerly been the case, follow 
the steps of the cholera from house to house, but should precede 
it. Disinfection is only important as a prophylactic. 

When the disease has been introduced into a house, and an 
indubitable case of cholera has occurred among the inmates, it 
will, as a rule, be too late to disinfect; and when the patient 
has been infected in the house itself, the opportunity of re- 
ceiving the poisen will usually have been afforded at the same 



_ 



81 

time to all the other inmates; and it will depend essentially 
upon the condition of individuals whether or not the disease will 
be farther developed. Notwithstanding this, the use of disin- 
fectants should never be omitted in houses where cholera has 
appeared, since they will at least prevent the further develop- 
ment of the germs. 

When a case of cholera has appeared in a single house in a 
place, there is the more reason to hasten to disinfect the other 
houses, since the germs from the first may already have been 
conveyed to them, even before the nature of the disease has 
been medically and officially certified. 

The concealment or neglect of the first case of cholera in a 
place is one of the greatest errors that can be committed, and 
usually occasions more injury than can be afterwards retrieved 
by the greatest efforts and sacrifices. 

The water-closets of railway stations and hotels must be con- 
stantly disinfected so long as the introduction of cholera by 
travelers is to he feared. 

The foul linen of strangers in hotels must be disinfected before 
it is sent to a laundress. 

The period at which disinfection may be abandoned depends 
essentially upon whether the possibility of the introduction of 
germs, or the period of local predisposition to the disease, has 
ceased. In order to determine these points with sufficient ac- 
curacy to obtain a sure basis for practice, further investigations 
are required. 

Sixth. — Superintendence of Disinfection. 

The actual carrying out of the disinfection may be left to the 
owners of the separate houses, although it is better undertaken 
by the local authorities ; but in either case it requires careful 
modical supervision. This supervision must determine that no 
alkaline reaction shall occur in any place where excreta are col- 
lected or conveyed ; and that, if such should occur, it should 
immediately be supersaturated by acid. 

In order to show the acid reaction, it is sufficient to place a 



82 

drop of the fluid, fey means of a glass rod, upon a slip of Iitmts*- 
paper, and to observe that this is redened. 

When the reaction is alkaline, this may be shown by placing. 
a drop of the fluid in the same manner upon yellow turmeric 
paper, which will be turned to a red brown. 

If it is desired to test the air of drains, sewers, or pipes, for 
the presence of carbonate of ammonia, a slip of turmeric paper 
must be moistened with distilled water, and placed for half its 
length between two slips of glass. The whole must then be 
placed for a few minutes in the suspected air. The presence of 
the smallest quantity of ammonia will produce a marked differ- 
ence in color between the covered and the uncovered portions 
of the paper. 

Seventh. — Limitation of Intercourse. 

Since it is not to be doubted that the spread of cholera de- 
pends upon the intercommunication of mankind, it may be as- 
sumed that the spread would cease if all communication were 
suspended. But, as a complete suspension of intercourse would 
be a greater calamity than cholera itself, so have all ordinances 
tending in such a direction proved hitherto fruitless and illusory. 
Our efforts must be limited to an endeavor to render inter-' 
course harmless, by strict enforcement of disinfection. 

If the present opinions about the conveyance of germs, and 
about the essential nature of disinfection, be correct, it follows 
that the latter may afford as complete a protection as absolute 
arrest of intercourse, or as the natural immunity of certain 
places. 

It is only on the sea-coast and in sea-ports that an arrest of 
intercourse can be enforced with good results; when ships 
coming from infected ports are prevented from landing anything 
until after the lapse of the longest period of incubation that has 
been observed in cholera; or when the crew and passengers are 
kept in strict quarantine for the same period of time. 

Such quarantine should be maintained for at least four weeks, 
and should be so arranged that the arrivals can communicate no- 
infection to persons departing. 



'Hie disinfecting regulations must be most eareiuliy observed 
in all quarantine establishments. 

Section Second. — On the Local or Temporary Predisposition. 

The local or temporary predisposition is chiefly influenced, 
"according to the present state of the inquiry, by the permeability 
of the soil by water and air 7 by its varying fluid contents, and 
by its being impregnated with organic and decaying nitrogenous 
materials. 

A soil that is impermeable, or but slightly permeable, by ail 
and water (a elose rocky soil, for example,) is little or not at all 
liable to an epidemic outbreak. 

Porous soils, and even rocky soils that are split up by 
numerous and deep fissures, filled in with earth, do not afford 
the same protection. 

When an impregnated porous soil has been unusually 
'saturated witli moisture, so that the air has been forced out of 
it for an unusual time and to an unusual height by water, the 
^apid subsidence of the water favors the epidemic development 
of cholera in such places. 

The more the surface layers are impregnated with decaying 
organic matter, the more dangerous will be the recession of the 
surface water, in case the germ of cholera should be introduced 
at the time. 

The recession of surface water, and the consequent drying of 
soil that has been thoroughly soaked for some time, appear to 
he of the greatest weight with regard to the time of outbreak of 
a cholera epidemic. 

In river channels, in valleys, and at the feet of steep cle* 
■clivities, the above three factors are often in combined action \ 
since these conditions of surface promote the formation, collec* 
tion, stagnation, and variation of surface water. 

Localities upon a ridge between two valleys, or between two 
water-sheds, show generally a much less degree of predispo- 
sition. 

The courses of rivers very constantly show a less predispe»« 
&ition the nearer they approach to their water-sheds. 



m 

Against peculiarities of soil, surface water, and poisonous nfiv 
pregnation, scarcely anything can be attempted at short notice. 
When the introduction of cholera germs coincides with the 
presence of these three factors in an unfavorable sense, there is 
nothing to be done, save disinfection, but to avoid or desert the 
locality. 

The above considerations are highly important, not only for 
those who fly from cholera, but also as guides in the choice of 
places for cholera hospitals or quarantine stations, and of camp- 
ing grounds lor soldiers, railway-makers, or other workmen. 
Although it may often happen, in war, that strategic considera- 
tions have little choice of place, yet still this choice should be 
exercised as far as the demands of strategy will permit. A 
judicious preference of high levels with compact subsoil is all 
the more important, when it is impossible to insure perfect dis- 
infection of all excreta. 

Section Third.-^Upon Individual Predisposition. 

tn every house or place attacked by cholera, the greater 
number of the inmates are equally exposed to the epidemic in- 
fluences of the germs and of the soil y and most of them ex- 
perience at the time of an epidemic some change in tneir con- 
dition, although it is only in a comparatively small number that 
this change amounts to a dangerous outbreak of disease. The 
power of resistance against the epidemic is very different in 
different people. 

In so far as the transudation of water from various organs 
into the intestinal canal is the most essential phenomenon of 
cholera, everything is of importance to the individual by which 
such transudation is promoted, favored, or occasioned. Among 
such influences are all by which the bowels aro overmuch irra- 
tated or relaxed, all which drive the circulation from the 
surface of the body to internal organs, and all which either in- 
crease the normal fluid contents of the organs, or retard the 
normal discharge of water from the body. 

Every person, therefore, should carefully avoid all influences 



tm 



'which his experience tells him are likely to produce diarrhsea im 
his own case ; and, if attacked by diarrhssa, should immediately 
seek medical aid. Medical house to house visitation of the 
healthy, so as to detect all illness at its commencement, has, in 
in all epidemics, been of the greatest benefit to the poorer 
classes. 

The establishment of stations for the care and observation of 
persons suffering only from diarrhoea, besides the special cholera 
hospitals, is greatly to be recommended. For such stations 
healthily-placed localities should be selected. 

A natural state of constitution being presupposed, a great in- 
fluence is exerted on the general condition of the body by food, 
drink, clothing, residence and occupation. 

The consumption of tainted provisions and of impure water 
is, of course, to be avoided. The diet should be moderate, but 
supporting. A suitable blending of well-cooked soup, meat and 
"bread, in quantities proportioned to the digestive power, with 
light puddings of eggs and flour, and with vegetables is to be re- 
commended. 

A large consumption of any kind of fluid should be avoided j 
and only so much taken, either of water, wine or beer as may 
he needed to satisfy thirst. Persons who are habitual spirit- 
drinkers in any quantity furnish numerous victims to the dis- 
ease. The drinking water should be pure and bright, the alco- 
holic drinks genuine and well fermented. 

A sudden change of diet produces no immediate correspond- 
ing improvement in the state of the bodily organs ; and it is 
often some weeks before the general condition is raised to the 
level of a better diet. At times^, when cholera is approaching or 
has appeared, the whole population should be better nourished 
than usual. 

The clothing should afford a sufficient protection from cold, 
without checking transpiration. Being chilled will often drive 
the circulation from the surface of the body, and occasion con- 
gestion of internal organs or catarrh of the mucous membranes. 
ITJie .abdomen especially should be warmly clothed, which may 



be suitably done by a flannel bandage. Good beds and eleam 
linen are important aids to uninterrupted transpiration. 

Promotion of the functions of the skin by internal means, 
such as warm drinks (peppermint tea, chamomile tea, warm 
wine and the like,) is a matter that should be left to the medi- 
cal judgment in each individual case. The same rule applies to 
the use of vapor, Roman or Turkish baths. 

The dwelling has the greatest influence upon the air that we 
breathe, that constantly surrounds us, and that uninterupt- 
edly must yield us oxygen, and must draw from us proportion- 
ate amounts of heat, water, and carbonic acid, in order to pre- 
serve the normal condition of our bodies. Long continuance in 
a confined atmosphere, which withdraws too little water and 
carbonic acid, is shown, by experience, to increase the disposi- 
tion to cholera in a high degree. The absence of fresh air, bad 
ventilation between the decks of overcrowded ships, in crowded 
barracks, prisons,, or rooms that are too small for the number 
of inhabitants, has been shown, by much experience, to be a fre- 
quent cause for violent choleraic outbreaks. Among persons 
who have received the cholera germs in some infected place, and. 
have afterwards been compelled to live in too little (that is, in. 
much vitiated) air, the individual predisposieion will be so much, 
increased in a few days that many will be attacked by the fully 
developed disease ; while others, infected at the same place, but 
afterwards living in a better air, often suffer very little ,or even 
not at all. 

During a cholera epidemic, therefore, all dwellings should be 
well and uninterruptedly ventilated, and kept thoroughly clean. 
The perils which are frequently and erroneously ascribed tc* 
too great a current of air, to what is called a " draught," may 
be obviated much better by clothing, bedding, heating, etc.,. 
than by shutting up the doors and windows. 

No one can believe that the inclosed air of a house is better 
than the air of the street; but the house can not generate its air- 
for itself, and must obtain it from the street, generally in it&. 
immediate vicinity. 



In a foul and stinking atmosphere the pernicious elements 
can not be destroyed by an admixture of strong smelling mat- 
ter (fumigation) j but, as a rule, the objectionable smell is only 
concealed by another that is stronger, although more bearable. 
The air can only be improved by ventilation, which dilutes all 
foreign matter contained in it. 

The smaller or more crowded any house or chamber, the 
more necessary is complete ventilation. 

It is a practice, sanctioned by long custom, to place chloride 
of lime in rooms containing a tainted atmosphere; although 
there is no proof of the smallest benefit from doing so. Chlo- 
rine certainly produces changes in most organic substances ; 
but, if it were introduced in sufficient quantity for the disinfec- 
tion of a dwelling-room, it would render the air of the room no 
longer respirable. We ought not to forget, moreover, that the 
Imman body is itself an organic substance, which the chlorine 
may attack. 

If it be desired, during a cholera epidemic, besides a sufficient 
ventilation, to diffuse some odor through a dwelling room or 
sick chamber, the purpose is best fulfilled by some volatile acid, 
together with some aethereal oils. The acid should not affect 
the respiration. The sprinkling or evaporation of vinegar, or 
of acetic acid, in such quantity as to fill the air with the odor, 
can never be hurtful ; and the acetic acid, on the principle al- 
ready laid down, may be supposed to exert some power as a 
■disinfectant. 

Occupation and bodily movement, in a certain degree, are not 
only conducive to health, but possitively essential to its preser- 
vation They must not be carried too far, nor allowed to pro- 
duce great fatigue or exhaustion. Excessive exertion has a 
dispreposing influence to disease, like debauchery, or excesses 
of any other kind, over-eating or drinking, acute emotions, etc. 

Where a daily regular occupation is necessarily followed in a 
room, daily exercise should also be taken for some time in the 
open air On days when the weather prevents going out, the 
-©xtirciae may be taken in a room with open windows. 



88 

Section Fourth — Regulations for Armies in the Field, 

Even for armies in the field it may often be very possible to 
guard against cholera, and to check its extension and its dan- 
gers, both for the troops themselves, and the population of the 
seat of war. The claims of war will, in very many cases, not 
preclude due carrying out of prophylactic measures ; and even 
for military results such measures will often prove of greater 
advantage than successful battles. 

1. It is self-evident that places where cholera prevails should 
generally be avoided by troops on the march. It is true that to 
march through such a place, without halting, may be considered 
free from danger; but any halt, even for a few hours, either of 
detachments or individuals, may bring cholera into the army — 
to break out mostly soon, but possibly only in from two to four 
weeks after its introduction. It is under all circumstances ad- 
visable for troops to encamp in the neighboring open country, 
rather than go into quarters in a town infected by cholera. In 
large towns it may often happen that cholera is epidemic in cer- 
tain parts, while others remain free on account of local advan- 
tages. When the military occupation of such a town appears to 
be necessary, the troops should take possession of the healthy 
parts only ; and all traffic with the infected districts should be 
strictly prohibited. When a division is joined by recruits or re- 
inforcements that come from places where the cholera exists, 
although they do not bring any diseased persons with- them, it 
is prudent to quarter the new-corners in a detached position for 
at least fourteen days, there- to undergo careful investigation 
and disinfection. 

2. Where the possibility of cholera exists, we should select 
the highest possible places, and the dryest and hardest ground, 
such as the ridge of a water-shed, for the encampment of troops, 
and never excavated or moist ground. All excrements should 
be disinfected as a prophylactic measure. 

3. If any cases of cholera or suspicious cases of diarrhgsa^ 
show thenaselves, then — 



89 

a. All cholera cases should be immediately separated, and 
placed in a special hospital at some little distance, or, still 
better, in tents or huts. These should be set up at one side of 
the positition of the troops, and on the dryest and most com- 
pact soil that is accessible ; and the evacuations and clothing of 
the sick are to be treated in the way already described. 

b. The cases of diarrhoea should also, when circumstances al- 
low, be kept separate, and brought to special stations for obser- 
vation ana treatment, to prevent the outbreak of cholera ; these 
evacuations being constantly disinfected by sulphate of iron. 
"Where the circumstances do not allow this, .the men suffering 
from diarahcea should at least be relieved from arduous duty, 
should receive an improved diet, and should be made to wear an 
abdominal bandage, and to take proper medicines, especially 
small doses of opium. It must be made a point of duty for every 
man attacked w r ith diarrhoea to report himself immediately to 
the surgeon ) and daily medical inspection should be made with 
regard to fresh cases, and of the state of those already under 
treatment. 

c. When cholera threatens an army, each division must have 
a diet regulated in the manner above laid down. The men 
must be cautioned against drinking much water, or much drink 
of any kind, against sour provisions, unripe fruit, and the like, 
and must take a comparatively dry flesh diet, with coffee, and a 
little brandy. 

d. All fatigue and exertions of the troops that is not impera- 
tively required should be forbidden during cholera time ', such 
exhaustion certainly increases the liability to the disease. 

e. The existence of cholera in an army should never be con- 
cealed; and if a division suffering from it is coming into a town 
previously free, the presence of the disease should be made 
known at once, and even before the arrival of the men, in order 
that the proper disinfectant and prophylactic measures should 
immediately be commenced. 

4. Any division of an army that has already suffered from 
cholera obtains thereby, for a long time, a diminished predis- 



90 

position, or even immunity. If, therefore, it is necessary to oc- 
cupy or to reconoitre a neighborhood that is infected, and 
troops so seasoned are to be had, they should be selected in pre- 
ference to all others. 

B. SCHEME EOE THE OBSERVATION OF CHOLERA EPIDEMICS. 

1. 

In the first place, the manner of the occurrence of the first 
case of cholera in any place must be inquired into. 

The chief questions are : 

Had the person first attacked visited within four weeks any 
place in which cholera prevailed ? 

Are there, in the house in which the case first occurred, stran- 
gers arrived from any place where there is cholera ? If so, are 
they, a, cholera patients, (3, diarrhcea cases, y, healthy persons, 
<5, corpses dead from cholera? 

Have any effects from a cholera place, especially the soiled 
linen of cholera patients, been brought to the house? 

Has the person first attacked visited, if he has not inhabited, 
houses into which cholera germs may have been introduced in 
any of the ways mentioned above ? 

What description of individuals was the first attacked ? 

Hss he been exposed to any powerful occasional cause ? 

What sort of care did he receive ? 

The time and place of the commencement of the first attack 
should be noted with great care. 

2. 

With regard to the observation of the spread of the epidemic 
in a place, the first thing is to collect, from first to last, a daily 
list of occurring cases and of deaths; with mention of the bouse 
story, age, sex and condition. The deaths should be published 
daily, with the streets and numbers of the houses ; but the oc- 
curring cases should not be published. 

The inquiry should be conducted, as far as practicable, into 
the occurrence of cases in which the infection has been conveyed 
by individuals or fomites; and any clear and undoubted exam- 



^■■M 



pie of the conveyance of the disease, in which the influence of 
the soil and place of residence could be satisfactorily excluded, 
should be scrutinized with the closest observation. 

The possible action of infectious matter in a recent or already 
dry and changed condition, as in soiled linen and clothing is to 
be noticed. 

Any clear and certain facts about the time of incubation of 
the disease should be recorded. 

Positive and negative testimony should be collected with re- 
gard to the spread of the disease to neighboring places, and with 
regard to the means of its extension. Also with regard to its 
extension along lines of railway. 

Special investigation is required where the disease has been 
epidemic in autumn; and, after a pause during winter, has bro- 
ken out afresh in the same place in the spring. 

3. 

Concerning the auxiliary cause of an epidemic, the attention 
should first be directed to the geological character of the soil 
in the locality generally, and to the condition and pecu- 
liarities of the substrata of the houses most severely visited 
(after the close of the epidemic, to those also that were least 
visited^, whether they be rock, loose stone, detritus, sand or 
loam. The strata of the locality should be observed from the 
surface to the bottom of the water springs. Where different 
strata overlie one another, their average height should be given i 
and it should be noticed whether one or other of them may oc- 
casion collections of surface-water from time to time. 

Attention should next be directed to the level of the surface- 
water. If no former observations have been made upon this- 
point, it is alwa} T s of interest to make them during the epi- 
demic, and to examine also the height of the neighboring- 
springs. Where these do not flow over or from the first imper- 
meable or water-guiding stratum, and where, therefore, the 
height of the springs is not a standard for that of the surface- 
water in the vicinity, special shafts should be made, in order &o 



92 

compare, the levels at the close of the epidemic with those of a 
later period. Information should also be sought from owners 
of springs, and from other trustworthy persons, with regard to 
the water-levels and the moisture of the soil at the period im- 
mediately preceding the epidemic. 

The houses that at the close of the epidemic have been most 
heavily visited must be the subject of special scrutiny, mostly 
of an obvious kind. Their high or low position, the stratum on 
which they stand, the position of neighboring sunken ground, 
the vicinity of running or stagnant water, or of heaps of pesti- 
lential matter, the building* materials of which they are con- 
structed, the degree of moisture of the houses themselves, and 
of the court-yards, the condition of their closets, sewers, and 
the effluvia from them, the number of inhabitants in each house, 
the state of nutrition and general health of the inmates, and the 
state of their sleeping-rooms, dwelling-rooms and workshops 
comprise the chief points that should be noticed. 

4. 

An actual extension of cholera has sometimes appeared to be 
due to drinking-water; and in other cases the first impression 
to this effect has been refuted by accurate examination. Inquiry 
should be made into the source from which the inmates of the 
severely-visited houses obtained their drinking-water, whether 
From the same source as many persons who remain unaffected. 
The peculiarities of any water suspected of propagating cholera 
shou'd be noted, especially whether it throws down any dirty 
deposit, or whether it is believed or can be proved to be con- 
taminated by cholera excrement. 

The constitution of the individuals attacked should be inquired 
into; with particular reference to any changes shortly before 
the outbreak of the disease. Any abuse of alcoholic drinks 
should be noted. Fear, colds, dietetic errors (their nature to be 
specified, and whether they 7 loaded the organs with too much 



■ 



93 

water, or affected the intestinal mucous membrane), misuse of 
medicines (what medicines), are all points to be observed. 

New and interesting observations may be made with regard 
to the action of the epidemic influence upon the healthy during 
the prevalence of cholera — that is, upon persons neither at- 
tacked by cholera or diarrhoea. Did they experience any scan- 
tiness of urine, any tendency to cramps, etc., etc. ? — and how 
far were such symptoms due to changes in their diet and man- 
ner of life. 

6. 

Meteorological observations during the epidemic are of no 
Value, except when compared with others previously kept over 
a long period or made at other places. 

Whether the general character of disease before and during 
the epidemic has changed — whether the epidemic was preceded 
by diarrhoea, typus and intermittent fever, and whether the two 
last-named were frequent and often complicated by pneumonia, 
are questions that should be determined, wherever possible, by 
statistical inquiry. 

Whether the epidemic has resembled previous ones or has 
been different from them, is a question to be determined at its 
termination. 

7. 

With regard to the termination of the epidemic, it should be 
noticed what circumstances appear to have influenced its close. 
Whether, to what extent and in what manner, disinfection has 
been practiced, and with what apparent result ? Whether house 
to house visitation has been practiced, and with what result ? 
Whether the use of prophylactic means has been attended with 
advantage ? Lastly, in what manner cholera cases have been 
treated in hospital j and what has been the influence of this 
treatment upon the mortality, as shown by critically examined 
statistics ? 

There still remain, with regard to cholera, many other ques- 
tions, the study and solution of which are of the greatest im- 



94 

jportan'ee. We have strictly confined ourselves to mentioning 
the matters most necessary for aetiology and prophylaxis, and 
easily to be carried out. • All besides we leave to the judgment 
■Of the inquirer and practitioner. 



£TSW YOKK ACADEMY OF MEDICINE Otf THE ^KEVEOTlYB 
AND REMEDIAL TREATMENT OF CHOLERA. 

[From Medical News ami Library, September, 1866 ] 

Whereas, The ^ew York Academy of Medicine has endeav- 
ored to promote among its own members) and throughout the 
medical profession, a spirit of exact and practical inquiry into 
the preventive and remedial treatment of epidemic cholera ; 
therefore be it 

Resolved, That this Academy hereby expresses its confidence 
in the utility of general and specific hygienic measures as the 
best means of prevention against the pestilential prevalence of 
cholera in any locality where it makes its appearance ; and that 
the most thorough scavenging, cleansing and disinfection are 
absolutely necessary means of averting this pestilence in the 
cities and populous towns of our country at the present time. 

Resolved, That in the judgment of the Academy the medical 
profession throughout the country should, for all practical pur* 
poses, act and advise in accordance with the hypothesis (or the 
fact) that the cholera diarrhoea and i( rice-water discharges" of 
cholera patients are capable, in connection with well-known lo* 
calizing conditions, of propagating cholera poison; and that 
rigidly enforced precautions should be taken in every case of 
cholera to permanently disinfect or destroy those ejected fluids 
by means of active agents ; also, that with the same object in 
View, the strictest cleanliness of persons and premises should be 
enforced upon all who have charge of the sick; and all privies, 
water-closets and cesspools should be kept thoroughly under the 
control of disinfectants. 

Resolved, That we regard the nature and causes of cholera in* 
fection, so far as the sick or their discharges can propagate it> 



m 

as being so susceptible of control that there should be no fear of 
hesitancy in the personal care of the sick and all that pertains 
to them. 

Resolved, That immediate and thorough cleansing and disin* 
fection of all persons, clothing and things that have been ex- 
posed to the discharges or persons of the sick with cholera 
constitutes the chief end and object of any rational quarantine 
or external sanitary police regulation against cholera. 

Resolved, That for the purposes here mentioned, an external 
sanitary police is desirable in all great maritime and river 
towns, but that such sanitary regulations need not seriously em- 
barrass commercial intercourse and the interests of trade. 

Resolved, That the main source of protection against epidemic 
cholera at the present time is to be found in the vigilant and 
effective operation of sanitary measures, municipal, domestic 
and personal. 

Resolved, That the New York Academy of Medicine cordially 
invites the physicians of every city and village throughout our 
country to urge the immediate adoption of adequate measures 
of sanitary protection against the introduction and ravages of 
cholera, and to this end we pledge our brethren and the public 
the hearty and continued co-operation of this Academy. 

The above resolutions were unanimously adopted by the 
Academy. 



QUARANTINE AND CHOLERA. 
[From Lancet, May 12, 1866.] 

The tendency of professional men in this country (England) 
to repose less and less faith, or altogether to disbelieve in the 
efficaciousness of quarantine as a defense against cholera has 
been rudely shaken by the circumstances attending the diffusion 
of the disease since the beginning of 1865. In some instances 
the pestilence is known to have been taken on board ship at 
Alexandria, to have been carried in an active state over hun- 
dreds or thousands of miles of sea-route, to have been landed in 



96 , 

a seaport town in another country, and there to have assumed a 
formidable and most fatal development. In other instances the 
outbreak of the malady in the coast towns of Europe has been 
preceded by events which could leave little doubt that the dis- 
ease had been imported amongst their population in a like man- 
ner, and from the same source. Finally, the whole history of 
the progress of the epidemic, from its point of origin to its ex- 
tremest limits of dispersion, indicated the dissemination of the 
disease from Alexandria to the shores of the continent in the 
first place, and its subsequent extension from the centres of in- 
fection thus set up. 

The appearance of the malady at Southampton last autumn, 
and the recent importation of cases into this country from Kot- 
terdam, as well as transmission of cholera-poison across the 
country to receive a deadly development out at sea and in the 
ports of the New World, have seemingly clinched the lesson 
taught by the previous progress of the epidemic, and awakened 
a serious doubt of the wisdom of that want of faith in quaran- 
tine which has grown up among us. 



QUARANTINE AND CHOLERA. 
[From Medical Times and Gazette, April H, 1866.] 

Dr. Bowerbank, in an article entitled " Lessons from the 
Cholera at Jamaica/' says: "I have had no proof that any of 
the visitations I have seen were traceable to importation by a 
particular vessel ; but I have known cholera introduced into a 
district and an island, and the disease not extend itself ; thus, at 
any rate, proving that something more than mere introduction 
of the disease was necessary to its extension, and over which 
quarantine could exercise no influence. That cholera attacks 
certain districts or places, certain towns and streets, certain 
houses and rooms, and during the prevalence of an epidemic 
nestles there, I am confident, and I believe that in every such 
instance a bad sanitary status will be found to exist. 

" The great preventives of cholera and all other epidemic dis- 



H 



97 

eases £fe pure air ; pure water, plenty of daylight, and cleanli- 
ness in its widest acceptation. Where these essentials to health 
exist, cholera may come, and proclaim its presence by the oc- 
currence of diarrhoea, borborygmi, cramps and other well- 
known symptoms, and it may seize as a victim a person predis- 
posed to disease by intemperance or depression of body or 
mind, but here it will not nestle. 

" During the epidemic of 1850, I have known towns and vil- 
lages nearly depopulated ; whole yards and houses, ships in 
port, swept clean, and not an inmate left to tell the tale. But 
in all such cases neglect of sanitary measures, and the open vio- 
lation of JSTature's laws explained the cause. It will thus be seen 
I am of the opinion that wc have no power to exclude epidemic 
cholera. This mysterious visitor will come to our shores in spite 
of us ; but we have the power to lessen its ravages and deprive- 
it of its sting, and in effecting this we at the same time adopt 
the best means to rid us of those less dreaded (because more 
familiar and slower in their course) but more fatal scourges of 
our population, typhus and typhoid fever, and the entire class 
of tuberculous disease. 

"< Prevention is better than cure/ In no instance is the 
truth of this adage more obvious than as regards a visitation of 
epidemic cholera. Experience in all parts ol the known world 
has taught us that its ravages may be lessened or prevented by 
judicious sanitary measures ; but where these have been neglect- 
ed, for a time at least, after its advent, this disease resists or is 
but little amenable to curative treatment, In case of the out- 
break of cholera in a notoriously unhealthy district, I believe, as 
regards the mass of the people, instead of, as hitherto, adopting 
the house to-house visitation system and the unprofessional and 

wholesale administration of medicines, it would be far better 
that arrangements should be made to transfer the inhabitants^, 

or as many as possible of them, to another place, even though 

it should be requisite to provide tents or allow them to remain 

Uncovered." 



98 

EXILES FOE THE TEEATMENT OF EPIDEMIC DIAEEHCEA AND 

CHOLEEA. 

By George Johnson, M. D., F. R C. P., Phyf-ican to King's College Hospital ; 
Professor of Medicine in King'd college, &e. 

[British Medcal Journal, July 21, 1S66 . ] 

Dr. G. Johnson sums up his matured views of the treatment 
of epidemic diarrhoea and cholera as follows : 

"It may be stated as a general proposition, that the immedi- 
ate cause of diarrhoea or looseness of the bowels is the presence 
of offending materials in the alimentary canal. These offending 
materials are of various kinds in different classes of cases. In 
one case, unwholesome and undigested food is the exciting cause 
of the purging; in another case a large and unnatural accumu- 
lation of the feculent contents of the bowel; while, in. another 
class of cases, offending materials are poured from the blood 
into the bowel, in censequer.ee of the action of a morbid poison 
upon the ingredients of the blood. To this last class of cases 
belongs what is called choleraic diarrhoea. 

" The most rational theory of choleraic diarrhoea is, that a 
morbid poison enters the blood either with the air, through the 
lungs, or with the food and drink through the alimentary canal ; 
and that this poison excites certain changes in the blood, in con- 
sequence of which some blood-materials are spoiled, and thus 
rendered not only useless, but noxious. These morbidly changed 
blood-materials are then discharged from the blood-vessels 
through the mucous membrane of the stomach and bowels, and 
are ultimately ejected by vomit ; ng and purging. 

" Yarious as are the remote and primary causes of diarrhoea, 
this one condition is common to all classes of cases, viz., that 
the contents of the bowel are unnatural and offensive. These 
offending materials are the immediate cause of the purging; and 
they must be expelled from the bowel before the diarrhoea can 
come to an end. 

"From the above considerations we deduce one important 
and guiding rule of treatment, which is this — not to attempt by 
opiates, or by other directly repressive means, to arrest a diarrhoea, 
while there is reason to believe that the bowel contains a consider- 



m 

tibU timo'uxij of morbid and offensive materials. It is certain tliat 
these offending materials must ibe cast out from the bowel before 
the diarrhoea can permanently cease. The effect of an opiate at 
this stage is to prolong the disease, and to increase the risk of 
mischief from the retention and reabsorption of the morb'd con- 
tents of the bowel. If the opiate have the effect of retaining 
within the blood-vessels some of the morbidly changed folood- 
oonstituents, this astringent action will probably be more in- 
jurious, and even deadly, than the retention of morbid secre- 
tions within the bowel. 

" The purging is the natural way of getting rid of the irritant 
cause. We may famr recovery by directing the patient to 
drink copiously any simple diluent liquid — water, cold or tepid> 
toast-water, barley water, or weak tea; and some safe purgative, 
and then, if necessary, soothing it by an opiate. Castor-oil, 
notwithstanding its unpleasant taste, is, on the whole, the safest 
and the best purgative for this purpose. It has the advantage 
of being very mild and unirritating, yet withal very quick in its 
action. A tablespoonful of the oil may be taken, floating on 
cold water or any other simple liquid which may be preferred 
by the patient, A mixture of orange-juice or of lemon-juice 
with water forms an agreeable vehicle for the oil. If the dose 
be vomited, it should be repeated immediately; and the patient 
should lie still, and take no. more liquid for half an hour, by 
which time the oil will have passed from the stomach into the 
bowels. Within an hour or two the oil will usually have acted 
freely. Then a tablespoonful of brandy may be taken in some 
thin arrowroot or gruel; and if there be much feeling of irrita^- 
tion, with a sense of sinking, from five to ten drops of laudanum 
may be- given in cold water. These means will suffice for the 
speedy cure of most cases of choleraic diarrhoea. If the patient 
have an insuperable objection to castor-oil, or the oil cannot be 
retained on the stomach, ten or fifteen grains of powdered 
rhubarb, or a tablespoonful of the tincture of rhubarb, or a tea- 
spoonful of Gregory's powder, may be substituted for the oil. 

u If the diarrhoea Jiave continued for some hours, the stools 



100' 

Raving been copious and liquid ; if there be no griping pain in €h& 
bowels, no feeling or appearance of distension of the intestines J 
the" abdomen being flaccid and empty,' and the tongue clean — we" 
may conclude that the morbid agent has purged itself away. 
There will be, therefore, no need of the castor-oil or other laxa* 
tive, and we may immediately give the brandy in arrowroot, 
and the laudanum as before directed. The rule in all cases is, 
not to give the opiate until the morbid poison and its products have 
for the most part escaped ; not to close the door until l the enemy f 
has been expelled. While there are some cases in which the 
evacuant dose is not required even at the commencement of the 
attack, there are many others in which the opiate is unneces- 1 
sary in the latter stage. In some cases of severe and prolonged 
diarrhoea,, it may be necessary to repeat the oil and the lauda- 
num alternately more than once, at intervals of three or four 
hours. Practical skill and tact are required to discriminate 
these cases. 

" If the diarrhoea be associated with vomiting, this should be 
encouraged and assisted by copious draughts of tepid water*. 
The vomiting affords relief, partly by the stimulus which it 
gives to the circulation, but mainly by the speedy ejection of 
the morbid secretions. 

#< Thirst may be allayed by drinking cold water, which may 
be acidulated hj the additon of lemon -juice or a few drops of di- 
lute sulphuric acid Care should be taken that the water for 
drinking is pure. Organic impurities, such as result from the 
admixture of sewerage, are especially to be dreaded. If the 
water be of doubtful purity, it should be carefully filtered 
through sand and charcoal, and then boiled. Impure water is 
a common exciting cause of cholera. 

" While the diarrhoea continues, the diet should consist of ric© 
or arrowroot, gruel or broth. 

"In all cases of severe diarrhoea the patient should remain in* 
bed. 

" If the purging continue, if the stools become colorless and: 
watery (the purging being of the kind commonly called rice-* 



101 

water purging), and if the surface of the body become isold and 
i)lue, the disease is now passing, or has actually passed, into a 
stage of collapse. 

" This state of choleraic collapse results from a peculiar arrest 
of blood through the lungs, occasioned by a morbid poison. It 
is not a condition of mere exhaustion. It is not relieved by the 
remedies for exhaustion ; and it is made worse by opiates and 
<by spiritous stimulants, which must therefore be avoided. The 
patient should be strictly kept in the recumbent position ; he 
should be allowed to drink pure water freely; and should be 
.abundantly supplied with fresh air. Hot flannels or bottles, or 
bags of sand, should be applied to the feet and legs. 

u Cramps may be relieved by rubbing the affected parts with 
the warm hand. 

" Hot baths, whether of water or of air, have been found to 
be, on the whole, more distressing and exhausting than beneficial 

"Five grains of sesquicarbonate of ammonia, or a teaspoon- 
ful of spirit of sal volatile, may be given in an ounce of camphor 
mixture every two or three hours as a diffusible stimulant. 

" The discharges from the bowels, and the condition of the 
abdomen, should be carefully observed. The discharges always 
continue, more or less, during the stage of collapse, and until 
reaction has set in. One of the earliest and surest signs of re- 
action is the reappearance of bile in the vomited matters and in 
the stools Wben vomiting and purging entirely cease during 
the stage of collapse, the disease is nearly always fatal. 

u One of the main objects of treatment during this stage is to 
facilitate the escape of morbid secretions from the alimentary 
canal. This may be done partly by the use of diluent drinks, 
,and partly by an occasional dose of castor-oil. If we carefully 
observe the condition of a patient in collapse^ we shall often find 
that the intestines are more or less distended with liquid, and 
this, too, while, perhaps, there is general torpor and little or no 
effort at expulsion. Again, it has often been found that, al- 
though there has been a copious watery purging during life, the 
small intestines contain, after death, a large amount of a pee&- 



202 

liar viscid, dirty white material, having a very offensive odor: 
An occasional dose of castor-oil — a tablespoonful every three or 
four hours during the stage of collapse — may be- useful in re- 
moving both these conditions; namely, over-distension of the 
bowel by liquid,, and accumulation and retention of offensive, 
viscid, semi-solid secretions. 

"The object and the effect of this treatment are not to in- 
crease the amount of liquid which is poured from the blood into 
the stomach and bowels, but simply to assist and quicken the 
expulsion of the morbid secretions from the alimentary canal. 

"After reaction has occurred an occasional laxative dose is; 
required— about once in twenty-four hours during the first 
two or three days. 

"It is worse than useless to attempt to feed a patient during 
collapse. The secretions of the stomach are utterly deranged; 
and the power of digestion is suspended. The mildest nourish- 
ment administered at this time only adds to the feeling of op- 
pression and general distress,, from which the act of vomiting 
often gives immediate relief. 

"After reaction has occurred, and when the normal secretions 
are restored, the mildest nourishment should be given fre- 
quently, but in small quantities — such as milk, gruel, or rice, or 
arrowroot, with a small quantity of brandy, soup, or beef tea, 
or chicken-broth. After an attack of cholera, the stomach is 
sometimes long in recovering its tone and the power to digest 
solid food. When this is the case, a grain of quinine, with ten 
or fifteen drops of dilute hydrochloric or sulphuric acid, and an 
equal quantity of chloric ether, may be taken with each meal. 
The same combination, too, often relieves that distressing sense 
of uneasiness, with flatulence in the stomach and bowels, expe- 
rienced by many persons who are not otherwise ill during an 
epidemic of cholera. 

" Venesection has often afforded great relief during the stage 
of collapse. The symptom which appears especially to call for- 
tius remedy is rapid breathing, with a feeling of impending 
suffocation. When, with these symptoms, there is a cessation; 



103 

of vomiting and purging, which is probably a result of the al- 
most entire arrest of the circulation through the lungs, I believe 
that veuesection affords the only hope of saving life. It is diffi- 
cult to obtain a stream of blood in these cases ; not, as many 
suppose, because the blood is too thick to flow, but because, in 
consequence of the block in the lungs, the blood in the veins is 
nearly stagnant. The bleeding appears to be beneficial, partly 
by relaxing spasm, and partly by lessening the distension of the 
right cavities of the heart, and so increasing their contractile 
power. Repeated doses of ammonia may help to quicken the 
circulation. 

" Consecutive Fever. — Eeaction from collapse is sometimes fol- 
lowed by a febrile condition — a hot skin, quick pulse, coated 
tongue, hurried breathing, often a scanty secretion, or even a 
complete suppression of urine, with drowsiness tending to pass 
into coma. These unfavorable symptoms are more common 
when, during the earlier stages of the disease, opium and alco- 
holic stimulants have been given ; but they may occur when no 
such means have been employed. 

"The best treatment consists in a scanty diet without alcohol, 
copious diluent drinks, with saline effervescing draughts, an oc- 
casional aperient, castor-oil, or sulphate of magnesia, or a Seid- 
litz powder; counter-irritation over the lungs and kidneys, and 
sometimes local bleeding to relieve congestion of those organs. 

" In some cases there is complaint of pain in the region of the 
stomach during convalesence. This may be relieved by the 
application of a few leeches over the seat of pain. If, after re- 
action, the stomach remain irritable, with frequent vomiting, 
iced water is an agreeable and efficacious remedy." 



DR. JOHNSON'S ELIMLNATIVE TREATMENT OF CHOLERA. 
[Merheal News and Library, August, 1866.] 

In our last number, p 103, we noticed a remark of Professor 
Johnson's which we regarded as a virtual abandonment of his 
eliminative treatment of cholera, Li a more recent, article 



104 

{Med. Times and Gazette, June 16, 1866,) there is a further ad- 
mission which we consider to the same effect, and shows that 
the Professor has been driven to great straits in defense of his 
doctrine. He says : 

"I am aware that many practitioners can not think of giving 
a purgative to a sufferer from cholera without a feeling of dread. 
I am sure that this dread is mainly the result of an imperfect 
apprehension of what a purgative is intended to do, and of what 
it actually doos. The disease is usually attended with a profuse 
drain of fluid from the blood. To increase that drain might be 
mischieviovs, and might be fatal. A few doses of castor-oil do not 
increase that peculiar excretion which constitutes the purging 
of cholera. I know that they do not, by actual observation; 
and if we look a little closely into the matter, we shall see that 
an ordinary purgative can not have the effect which is so much 
dreaded." 

Purgatives, then, according to Professor J., are not really 
eliminative. He may well ask, " what, then, is the object to be 
attained by emetics and purgatives in cholera V 9 " The object 
is," he says, "to stimulate the stomach and intestines to eject 
their morbid contents, which otherwise might be retained and 
absorbed." 

This is restricting his views of elimination within very nar- 
row limits, and castor-oil is only -required in those case3 in 
which the bowel is "over-distended and paralyzed by its accu- 
mulated contents," and the "choleraic discharges are but slow 
and imperfectly discharged without the aid of some artificial 
evacuant." 

Castor-oil is therefore not to be given as an eliminant to elim- 
inate a poison from the system, but simply as an evacuant to 
empty the bowels of their contents when nature fails to do this, 
which is surely only in exceptional cases. 






105 

ON THE RELATION BETWEEN CHOLERA AND THE DIARRHCEA 
WHICH ACCOMPANIES IT, AND THE TREATMENT OE THE 
LATTER DISEASE. 

By Sir Henry Cooper, M. D. 

[British Medical Journal, June 16, 1866.] 

From a review of these important questions, Sir Henry 
Cooper concludes that — 

" 1. In epidemics of cholera an unusual amount of diarrhoea 
prevails; it precedes cholera, and extends laterally beyond it. 

"2. In the ordinary course of an attack of cholera, diarrhoea 
is the first symptom, and is undoubtedly the first stage of the 
disease. 

" 3 This premonitory diarrhoea is not distinguishable by its 
history or symptoms from the sporadic or ordinary diarrhoea. 

" 4. Cases in which diarrhoea has been stayed do not pass 
into cholera, while those in which it has been neglected may 
and often do. 

" 5. The astringent mode of treatment is generally as effica- 
cious in arresting diarrhoea during cholera visitations as at ordi- 
nary times. 

"6. And as a corollary from the above, it is the duty of 
those in authority in cholera epidemic seasons to search out and 
arrest all cases of diarrhoea, by the organization of a sanitary 
police for the detection of the disease, and its treatment in its 
earliest stages." 



PROPHYLACTIC ARREST QF ASIATIC CHOLERA. 

Dr. Henry MacCormac states {Medical Press and Circular, 
June 6, 1866) that a if there be a therapeutic fact more certain 
than another, it is that our success in the treatment of Asiatic 
cholera will, c ceteris paribus, be in the exaot ratio of the recency 
of the treatment. 

" The truth of this statement was abundantly exemplified in 
the results of house to house visitations. In Glasgow, for exam- 
ple, after a system of house to house visitation, during cholera 
periods, had been once fairly organized, the mortality was sur- 



106 

prisingh' small. Cases of premonitory diarrhoea, for example, 
that, if neglected, would have run on to intractable and perhaps 
fatal cholera, were arrested b} T means of an opium pill and an 
opiate draught, with a mortality not exceeding one in 1.400. 
Nothing could be more astonishing or more entirely satisfactory. 

" During 1854, it was, that some alterations in the building 
took place, and a communication subsisting with the infected 
town, the Belfast District Asylum for the Insane, to which I was 
and am physician, was visited with cholera. It broke out with 
startling suddenness, and forty of the inmates very rapidly 
perished. Many of the inmates were very unfavorable subjects 
for the disease, and I began to fear for the whole establishment. 
Intimately convinced; however, of the infinite value of prevention, 
it occurred to me that if I could not only arrest, but anticipate 
the premonitory diarrhoea, I might also arrest the disease. I 
immediately had prepared some dilute sulphuric acid, of whose 
general efficacy in the treatment of choleraic diarrhoea, I had 
had ample experience ; without waiting for the preliminary 
diarrhoea, I say, I gave to every inmate in the establishment a 
daily dose of about a drachm of the dilute acid in peppermint 
water. The existing cases of the disease having run their course 
to death or recovery, no other instance of the malady occurred; 
and I had the unspeakable satisfaction, owing, as I am inti- 
mately convinced, to the prophylactic efficacy of the dilute acid, 
of witnessing the utter disappearance of the disease. 

*' I would strongly recommend, and as strongly urge upon the 
attention of the profession, and indeed the general public, the 
advisability, coupled, however, in every case with every prober 
general sanitary precaution, of having recourse, with respect to 
the entire community, of the prophylactic efficacy of dilute sul- 
phuric acid, and in the very manner in which I myself tested it. 
I firmly believe, ever and always neglecting no effective sanitary 
precaution, that it would make us virtually masters of the situ- 
ation, and render the ravages of Cholera really and truly a thing 
oi the past/' 



TKEATMENT OF PEEMONITOKY DIABKHCEA. 
[Medical Timed and Gazette, April 14, 1868.] 

Dr. Bowerbank says: " As regards the attacks of diarrhoea s© 
prevalent daring the visitations of cholera, I have seen all sorts 
of treatment employed — as mercurials, opiates, ipecacuanha, 
the mineral acids, laxatives, antacids, and astringents; and I 
have seen each and all succeed and fail in checking the disease;, 
in cases in which the looseness was troublesome and continuous, 
tending to dysentery, not infrequent after an attack of cholera, 
I have found strychnia of much service, either alone or in com- 
bination with iron. In prescribing strychnia in such cases, I 
generally gave it according to Marshall Hall's formula. In the 
majority of the eases of diarrhoea I think a little ginger tea, with 
a few grains of carbonate of soda, with attention to diet, proved 
sufficient. If there was pain, a few drops of some preparation 
of opium were added. In such cases, too, chloroform and chlo- 
rodyno prove of service ; but in all cases, even of diarrhoea, the 
treatment should be suited to the particular case." 

" As to the treatment of cholera," Dr, Bowerbank says, u My 
experience is, that at the commencement of an epidemic the 
majority of cases die, and appear to be unamenable to any cura- 
tive treatment. I have seen drugs without number tried, and 
have heard each and every one cried up for a time as a specific 
and certain cure, but have seen them again fail and put aside. 
I have seen and tried small and repeated doses of calomel ; also 
large doses of the same ; also small and monstrous doses of 
acetate of lead, the mineral acids, the alkalies, opiates, quinia^ 
ipecacuanha, belladonna, mineral and vegetables astringents, 
cajuput oil, eroton oil, castor oil, turpentine, creasote, nitrate of 
silver, sulphite of magnesia, tartar emetic, mustard, table salt in 
large doses, \ Stevens' saline powders,' charcoal, chlorate of 
potash, eupatoria or bitter bush, the fresh juice of the aloe, and 
many others ; spirituous stimulants to intoxication, carbonic 
acid gas, the so called l Liverpool mixture,' and other boasted 
formulae, warm baths, hot air baths, external frictions, enem;>ta 
of all kinds, saline injections into the veins ; — but, nevertheless 



IG8 

I fear the results have been very unsatisfactory on the whole* 
Few of the first cases got well, and if they did I could not satisfy 
myself that their doing so was the result of what they had 
taken. I am quite certain that in the epidemic of 1850 I saw 
much mischief done by the use of spirituous stimulants and of 
opiates; so that in the epidemic of 1854 I almost entirely ban- 
ished these remedies from my practice. Calomel and other 
mercurial preparations are, in certain cases and at certain stages 
of the disease, useful; but ihey have no specific effect, and in 
the hands of the unprofessional are calculated to do more harm 
than good. 

"■ I think I have seen more good to arise from the use of 
Stevens' powder than from any other mode of treatment— in 
fact, in 1854 I confined myself chiefly to ihis. Having read of 
the use of sea-water in the treatment of cholera, and from the 
difficulty of getting the saline powders prepared in sufficient 
quantity, Dv Campbell and myself were inclined to give sea- 
water a trial among the prisoners of the General Penitentiary 
in Kingston. We had backets of sea-water brought from a dis- 
tance from the shore, and this, well-iced by pieces of ice thrown 
into it, was doled out in small quantities to the sufferers; they 
drank it greedily, and strange to say, of the seventeen cases 
who took it all recovered. Unfortunately it was not tried till 
towards the decline of the epidemic. In almost every case after 
the fourth or sixth dose the alvine dejections beeame tinged 
with bile ; as also the contents of the stomach vomited." 



The treatment for the premonitory diarrhoea most insisted on 
by Dr. Maclean, Deput} 7 Inspector General and Professor of Mil- 
itary Medicine, is immediate recourse to the recumbent position, 
and the use of a warm stimulating draught in combination with 
opium. Dr. Maclean spoke highly of the formula for the mix- 
ture in the " Medical Field Companion," intended to a pro- 
mote reaction in diarrhoea and cholera:" Oil of aniseed, and oil 
of cajeput, of each one fluidrachm and a half j Haller's acid soiu- 



100 

iron, and tincture of cinnamon, ot each two drachms. The dose 
of this is ten to fifteen or twenty drops, with the addition of 
fifteen or twenty drops of tincture of opium, or Battley's sedative" 
solution. The mixture can be given again at short intervals. 
It is seldom necessary, or even expedient, to repeat the opiate. 
Great comfort and support is given at such a time by the use of 
a stout calico belt, lined with flannel, worn over the abdomen. 
Some care in diet is advisable for a few days. 

And at the conclusion of his able and interesting lecture at the 
Eoyal Victoria Hospital, Netley, he recapitulates. "Secure the 
best hygienic conditions possible for your patients ; avoid crowd- 
ing them ; give abundance of water to drink and ice to suck ; cor- 
rect cramps and inordinate vomiting by the internal and external 
use of chloroform ) apply external warmth and extra bedclothes 
if these are grateful to the patient, but if they make him restless 
do not press them. If the cuticular discharge is excessive, wipe 
the patient dry from time to time, disturbing him as little as 
possible. If vomiting be not excessive, and if the remedy does 
not excite it, ten drops of the mixture I have recommended in 
the premonitory diarrhoea may be given from time to time, 
chloroform being substituted if vomiting be urgent. As soon as 
vomiting ceases, you must support the patient by proper nutri- 
ment': At first I begin usually with thin arrowroot, well boiled, 
and flavored with a little aromatic. I give this, commencing 
with a teaspoonful at a time, giving every now and then a tea- 
spoonful of brandy in it, never over-distending the stomach. 
Instead of water, I now quench thirst with milk containing a 
little lime-water, and flavored, if it be at hand, with a few 
drops of curacoa. This may be often given to the patient with 
a little soda water. As reaction proceeds, I substitute strong 
beef-tea, or, better still, essence of meat,^ using it in the same 
cautious way — spoonful by spoonful, at proper intervals ; later 
still, eggs beat up with a little brandy, and flavored as before 
with curacoa, is often relished. The greatest caution is required 
not to disgust the patient, nor to re-excite vomiting, not to 
over-stimulate, and so to bring on cerebral symptoms during 



no 

febrile reaction. When patients are thus carefully nursed, it is 
"seldom that reaction is excessive. Nothing but mischief may 
be expected from over-anxiety to hasten forward convalesence 
by too freely pressing food and stimulants on the patient. It 
requires a great deal of drilling and care to get orderlies and 
half-instructed nurses to understand this ; and many cases go 
wrong from their over-anxiety to press both on those under 
their care. In a word, the treatment of cholera may be sum- 
med up in two words— good nursing. The difficulty is to obtain 
this when an epidemic rages."— Lancet, Feb. 3d and l?th, 1856 k 



ON THE PHYSIOLOGICAL FORMULA OF CHOLERA AND OF 

THE TREATMENT. 

By B. W. Richardson, M. A., M, D., F. R. C. P., Senior Physician to the Royal 
Infirmary for Diseases of the Chest. 

[Medical Times and Gazette, August 4, 1886.] 

Dr. Kichardson sustains the following theorems respecting 
cholera, and founds upon them certain definite rules of treats 
ment : 

1. The symptoms of cholera are due to the separation of 
water from the albumen of the blood and of the tissues. 

2. The separation of water from the blood in cholera is due 
either to a local osmotic change in the alimentary canal> or to 
a general osmotic change in the blood itself 

3. The collapse of cholera is due not only to the elimination 
of water from the system, but to the removal by the w^ater of 
the heat of fiuidity or latent heat of the tissues. 

From these theorems it follows that there are three lines of 
practice open in cholera. These are, with their application, as 
follows : 

h To arrest elimination. 

2. To supply the caloric of ftuidity. 

3. To restore the homogeneousness Of the blood. 

If we could see a certain and simple way of restoring the 
bomogeneousness of the blood, we should have in our hands an 



M 



tt: 



ill *4 

immediate antidote to cholera, and the third suggestion would 

become the first and only suggestion. Unfortunately we have -*-" 

jet, by continued experiment, to learn this antidote, and we %$ 

must, as a consequence, reserve the trial of it for the extreme 

stages of the disease— a last resource, ,^ 

To fulfil the first of these indications — viz., to arrest exu- 
dative discharge — there are only two sets of remedies known: •£*** 
opium, which acts, when it can be absorbed, on the involuntary 
nervous system, producing contraction of the capillary vessels 
of the alimentary surface (in the same manner as it produces 
contracti n of the pupil); and direct local astringents which act 
on the secretions of the canal-— viz , creasote, tannin, the min- 
eral acids, and some metallic salts. It must be clear that none 
of these arc curative remedies in the extreme sense of the term 

— that is to say, they are not direct remedies or antidotes for ' ^ 

the primary derangement. But by their astringent action they 
prevent the water of the body from being conveyed away, and 
in this sense they conserve the animal caloric represented in the 
■water, and which is absolutely lost when the water actually flows 
from the organism. 

To fulfil the second indication, to sustain the caloric, there are i »^ 

two methods open. One of these is to prevent, as far as is pos- ^ 

sible, the radiation of sensible heat from the body. The cholera 

patient bhould be treated in the same manner as a man who is .0 

exposed to extreme coldness of the air. His animal fire low.? 
and the conveyance of caloric in his system interfered with, the 
choleraic sufferer is the parallel of an Esquimaux exposed with" 
out shelter to polar air and deficiency of food. To expose a man 
reduced in temperature to any process that shall remove from 
him caloric, is contrary to all reason \ to give him the advantage 
of the hot bath and to maintain his temperature by efficient 
clothing is the most natural, as it is the most obviously useful 
procedure. One has only to see a few times how the physical 

forces of life improve when the patient, collapsed and cold, tern" •'*. 

porarily rallies in the hot bath, to be assured of the soundness 
of the practice. This, however, is not again a curative process 



112 

iii the direct sense, but conservative only : for the body, by its 
external surface, cannot absorb caloric unless there be actual 
destruction of its surface. 

It is still a desideratum to supply animal caloric, and thisj 
Br. Bichardson points out, may be accomplished to a marked 
degree by attention to the fluids which are given as drinks to 
choleraic patients. He denounces as utter folly, and almost 
worse, the practice of charging such patients with cold and iced 
drinks, Presuming that a choleraic sufferer is just sustaining 
his natural caloric at 96° Fahr., he does this b}^ the gradual con- 
solidation of his tissues, and the giving up from them their heat 
of fluidity. At this stage let there be given to him a pint of 
fluid at 40° Fahr., and straightway, from an equal weight of his 
body, there is extracted by equalization 28° Fahr. of caloric, 
which; as he is placed, will never again be applied for the pro- 
duction of force,. 

This plan of cooling down a cooling body is, according to Dr. 
Richardson's estimate, adding evil upon evil. To treat the dis- 
ease rationally, the reverse principle ought to be invariably car, 
ried out — that is to say, foods and drinks should be made the 
means for introducing heat abundantly. It seems to him, on 
this reasoning, to be an important point to produce a substance 
which shall, as a liquid food, supplj T tissue material, and with 
that heat. 

Taking advantage of the fact that crystallizable fat, when 
mixed with albumen, can be dissolved by the beat of water, 
which heat it fixes in becoming soluble, and gives up again on 
solidifying— Dr. Richardson set to work to produce a food hav^ 
ing the properties named. After numerous attempts the follow 
ing proved most successful^. 

Take of pure stearine, two ounces by weight ; of best fresh 
butter, two ounces ; of whites and yelks of eggs, well beaten up, 
eight ounces; of carbonate of soda, twenty grains; of chloride 
of sodium (common salt), eighty grains; of Water, two ounces. 

As to mode of prepartion for the food: First dissolve, 
with heat, the stearine and the butter until they are both 



113 

melted ; then add the carbonate of soda and common salt to the 
eggs, and when these salts are dissolved in the egg stuff, mix it 
with the oily fluid, taking care that the latter is not of a tem- 
perature above 140° Fahrenheit^ let the whole cool to a soft 
consistency, and finally, on a slab or a board, rub in the water 
with a broad spatula. The compound may now be placed in a 
wide-mouthed jar \ in a little time it settles into a moderately 
hard mass, and is ready for use. 

In administering this compound to the sick, take one ounce, 
or a tablespoonfnl ; place it in a large breakfast-cup, and rub it 
up equally with a teaspoonful of glycerine, or a teaspoonful of 
ordinary water, or a teaspoonful of fine sugar and water, or a 
teaspoonful of honey and water. Next pour upon the mass 
three ounces of water, actually boiling, and incorporate well. 
The solid substance will now briskly and evenly dissolve, and 
will be at once so cool that it can be drank. The thermome- 
ter plunged into it will only register from 130° to 135° Fahren- 
heit. In this process the heat of the boiling water has been 
mainly (allowance must be made for conduction and radiation) 
expended in rendering fluid the solid matter. We may estimate 
safely, that in addition to the sensible heat, 44° degrees have 
been rendered latent for every ounce of fluid at least, which heat 
will be yielded up to the tissues if the fluid make its way into 
them. 

Contrasted with the supply of a pint (pound) of ordinary 
water at 40°, a pint of this fluid would effect a difference equal 
to 204° of added heat to a pound weight of the substance of the 
organism. 

Dr. Eichardson adds, that the fluid food prepared as proposed 
above is very agreeable to the taste, and that it may be made 
the vehicle for conveying either solution of opium, creasote, or 
dilute sulphuric acid, in proper doses. He found, after taking- 
nine ounces of the fluid, no sensation of nausea or uneasiness, 
but in the coui\-e ot half an hour the surface of his body became 
very hot, and the heat increasing, remained unpleasantly hiu'h 
for several hours. For patients who would object to drink the 

G 



**fr 



114 

fluid while heated, it might be allowed to cool ten or e^en 
twenty degrees. A glass of port wine is easily miscible with 1 
four ounces of the fluid. 

The last indication of treatment is to endeavor to restore the 
homogeneousness of the blood, and to bring the red corpuscles 
into proper circulatory action. This can only be effected by 
injection direct into the veins, and we know, from experience, 
that in the last stages of collapse the injection of certain fluids 
into the veins has been attended by remarkable results ; the col- 
lapse has, for the time, ceased, and, in some instances, the 
appearances of recovery have been so decided that the most 
sanguine but delusive hopes have been raised. 

The great question to be settled is — What fluid shall be in- 
jected ? Blood has been injected and has failed ; milk has been 
injected, and has usually failed ; saline solutions have been in- 
jected, and have, as a general rule, failed ; simple warm water 
has been injected, and has, in its turn, failed. In short, none of 
these solutions have been potent in saving life, but one and all 
of them have, for a time, averted death. 

Tho reason why certain immediate but not lasting benefits 
have followed these various injections is, that they have always 
been injected after being heated up to blood-heat ; the caloric 
thus applied has been the underlying basis of the transient suc- 
cess. Hence we must consider the question of transfusion in a 
new light, or success from it will continue to be only temporary. 

In respect to transfusion in the collapse of cholera, there is as 
little difficulty in accounting for the ultimate failure of the pro- 
ceeding, as for the temporary success. The success depends on 
the infusion of caloric, the failure on the inability of the fluids 
injected to sustain the calorific activity. 

What then do we want in the way of a fluid ? Dr. Kichardson 
thinks that the fluid should contain digested and easily hydrating 
albumen ; fatty substance that would solidify at a low tempera- 
ture j a small quantity of saline matter, and a substance that 
will easily pick up the blood corpuscles, when they have been 
partially deprived of fluid, and restore them to their natural 



■ 



115 

form and character. He has worked upon drying blood to test 
for such a fluid, and at last has arrived at the following formula, 
"which, on blood out of the body at all events, answers the pur- 
ipose welk He gives the proportions for a pint of fiiud. 

Of white of egg take four ounces by weight, of common salt, 
one drachm j of carbonate of soda, one scruple ; of clarified ani- 
mal fat, one ounce j of pure glycerine, two ounces ; of watefj, 
sufficient to make one pint. In preparing, dissolve the common 
salt and carbonate of soda in the water, and having well whip- 
ped the albunren, add that also to the water. Place the mixture 
on a warm bath, and raise the temperature to 135° ; keep the 
mixture steadily stirred and digest at this temperature for on© 
hour. This constitutes an artificial serum, the albumen of 
which hydrates freely. Having taken the artificial serum off 
the bath, place the fat and glycerine together in a crucible, and 
melt the fat in the glycerine. When the process of solution of 
fat is complete, pour the solution into the artificial serum at of 
about 120°, and stir in carefully; set aside that the fluid may 
cool to 80° Fahrenheit, at which point all the fat that is insolu- 
ble at 80° will float on the surface ; take this off and filter 
through coarse paper or closely-woven cloth. 

The fluid thus obtained is of pinkish color, of alkaline reac- 
tion, of saline sweetish taste, and of specific gravity, 1038. It 
picks up semi- fluid, blood with instant readiness, and diffuses it 
most equally. Heated, it takes up one-third more caloric than 
does water in the same time, and in cooling it restores nearly 
one third more. 

From his experience with mere saline injections, Dr. Kichard*- 
son infers that the fluid might be injected, at a temperature of 
106°, into the veins of a collapsed adult, in the proportion of two 
pints at one time. 

In reference to the mode of injecting the veins, Dr. Kichard- 
son observes that the greatest mischief has arisen in transfu- 
sion, from errors in the operation. The operator should ever 
remember that in this process he is feeding, not forcing ; he 
should keep in mind how gradually nature feeds the veins by 



iw 

ine thoracic duct, and he should imitate her j there is nornece^ 
sity for force, none for hurry. 

Above all things, in feeding by the veins the syringe should 
he thrown aside ; it is a dangerous, bad instrument for the pur- 
pose. To replace it he has constructed a simple instrument 
which he has used with great success. 



<m THE USE OF "WAEM BATHS W CHOLERA. 

By Dr. A. Clarke, Physician to the London Hospital. 

[London Hospital Reports, TOl. iiL, 1866.] 

^jThe use of warm baths in the treatment of Gbolera eases ad- 
mitted into the London Hospital during the recent epidemic, 
would appear to have been followed by more beneficial effects 
than are commonly attributed to this method of relief in the 
disease* " Baths at a temperature of from 98° to 140° Fahr.," say 
Dr. Clarke's clinical reporters, " were given, with most marked 
effect, in about one hundred of the worst cases. In almost all 
the cases there was commonly, for a few seconds, difficulty of 
respiration ; and in many, for about the same period, an un- 
pleasant sensation of heat. In children, fright also contributed 
in causing some difficulty ; but generally, in less than a minute, 
the good effects of the bath became manifest. Cramps ceased, 
anxiety of mind vanished, pulse returned, or if originally to be 
felt, increased in volume and frequency. Many who had before 
fiaoaned or shouted incessantly with pain, began to converse 
tipon indifferent subjects^ or, in many oases, sank into tranquil 
slumber. Often recovery appeared to be the direct consequence 
of the bath, the improvement being permanent .; but in many 
more, removal from the bath became the signal for the return, 
more or less rapidly, of the former symptoms. 

e( The testimony ot all who had a fair opportunity of judging,, 
is unanimous as to the relief afforded by the warm baths, the 
most convincing being that of the patients, who, in some eases. 



117 

©raved incessantly for thern^ and remained in, at their own re- 
quest, for nearly an hour at a time. 

"In a very few cases no relief was derived, but those were 
cases of great collapse, where their employment had been dic- 
tated by despair rather than hy any hope of benefit/' 



A Mr. Frederick Smith writes to the Medical Press and €ir- 
eular, of August 2d, 1866, that Dr. Rubini, of Naples, has 
treated 592 cases of cholera with camphor, without the loss of 
a single case. The preparation used by Dr. E., was a tincture, 
of equal parts by weight, of camphor and concentrated spirits of 
wine raised to about 60 degrees overproof. 

The dose was four drops every five minutes, increased, accord- 
ing to the severity ot the symptoms, to as high as twenty drops, 
and in cases where the patient had been addicted to much wine 
and spirits, a small coffeespoonful was given every five minutes 
till the violence ot the symptoms were subdued. 

The same remedy was used successfully as a preventive, taken 
every morning on a little sugar. 

Dr. MeCloy, Resident Medical Officer at the Liverpool Parish 
Infirmary, reported nineteen cases of cholera treated on the 
Rubini plan, of which thirteen died. — Lancet, August 18, 1866. 

Dr. Braithwaite (See Retrospect, Part lii., page 273) thinks 
chloroform will prove to be the most important remedy in the 
early stages of cholera, as it has been found to be wonderfully 
efficacious in relaxing all kinds of spasmodic action, and will,, he 
■thinks, supersede all other remedies for that purpose, as bleed- 
ing, emetics, etc. "Its relaxing effects ean," he says, "be 
watched with the greatest nicety, and accompanied or followed, 
if reaction does not come on by the very gentle and judicious 
use of stimulants." 

Chloroform may be used internally, by the mouth, in doses 
of five to ten drops to an adult, and may be combined with the 
t&gual dose of si^irits of camphor, or of turpentine. But it would 



m 

be safer to apply it externally, as an embrocation, over the re- 
gion of the stomach, chest and abdomen. Take of chloroform; 
one-half ounce, hartshorn liniment one and a half ounces, mix 
in a vial, and keep, well corked. One to two teaspoonfuls may 
be rubbed on the parts which should be immediately covered 
with a piece of folded flannel. This liniment would probably be 
improved by the addition of spirits of camphor or of turpentine,.. 
or both, say one-half ounce each. 



CONCLUDING REMARKS. 

The causes which have been supposed by different authors to 
have an agency in the development of cholera resolve them- 
selves into three classes, to-wit : 

1st. Gaseous effluvia, diffusible in the atmosphere. 

2d. An animal or vegetable alkaliocl, diffusible- in water,, 
and in moist or porus solids. 

3d. Microscopic animal or vegetable organisms, diffusible in 
water or porus solids, and perhaps also in atmospheric air. 

Each of these classes affords in itself a field for scientific re- 
search, which may not as yet have been thoroughly explored ;; 
but enough has been demonstrated to satisfy the reader that the 
methods which have been proposed for preventing the outbreak 
and spread of' the disease are both scientific an-d rational ; for 
it matters little to- which of these classes the primary cause is 
referable — the only rational mode of preventing its development 
is to prevent decomposition in accumulations of effete organic 
matter, and the diffusion of its morbid products in the various 
media adapted for their dissemination. 

As to treatment of cholera, it would be difficult and perhaps 
injudicious for me to attempt hereto indicate a plan, which 
might be resorted to with safety under any and all circum- 
stances by inexperienced and unskilful hands ; for there are 
circumstances in all diseases, arising out of differences in their 
grade and stages, as, also- differences of ha.bit, temperament and 



119 

idiosyneracy of constitution, demanding modifications of treat- 
ment which it would be impossible for the unpracticed mind to 
discei n. 

But where it is necessary that something should be done in 
the absence of a physician, we would refer our readers to the 
measures suggested in several of the concluding articles. At 
the same time we would remind them that medicines are not 
always harmless; and if not judiciously administered, they may 
prove more disastrous than the diseases they are intended to 
cure. 

We hope these remarks will not disparage the real merit of 
the work, for, as we intimated in the preface, we would again 
reiterate that our main reliance should be upon the means of 
prevention, and not upon those of cure, which are but too often 
unavailing even in the hands of the most skillful physician. 

With reference to measures of prevention, it will perhaps 
facilitate our purpose to remark, further, that certain constitu- 
tional predispositions always tend to invoke the attack and to 
increase its fatality — and of which debility, and especially 
chronic debility and relaxation of the intestinal mucous mem- 
brane are most to be dreaded, and should be promptly attended 
to whenever there is a threatened outbreak of cholera. 

Such conditions may often be remedied by proper attention 
to diet and exercise in the open air. The diet should be nutri- 
tious, but plain and unirritating, and never taken in quantities 
to overtax the powers of digestion. In most cases of this 
'kind these measures will be sufficient to enable the digestive 
organs to resume their healthy tone and functions. But in some 
it may be necessary to aid these simple measures by the admin- 
istration of tonic medicines, of which the bitter vegetable infu- 
sions, the mineral acids, and some of the preparations of iron 
are usually the most appropriate. The infusion of quassia or 
of gentian, or columbo, one or two ounces, with a drachm of the 
infusion, syrup or tincture of rhubarb, twice or thrice daily, is a 
good, simple tonic — to which may be added, if necessary, 6 or 8 
drops of the tincture >of iron, oroperly diluted with sweetened 



120 

water, or 1 to 3 or 4 drops of sulphuric, nitric or hydrochloric 
acid similarly diluted will be appropriate in some cases. But 
when practicable the preparations of iron and the mineral acids 
should always be taken under the advice and directions of a 
physician. 

If the debility and indigestion should be attended with pain, 
they are probably associated with some degree of inflammation 
or irritation, and their treatment will require the judgment of a 
physician. 

I can not too urgently impress the importance of temperance. 
Persons who are addicted to intemperance and other habits of 
dissipation are particularly obnoxious to cholera, and when at- 
tacked they seldom recover — a solemn warning to those who 
are constantly abusing their powers by intemperate and disso- 
lute habits. 

You should avoid exascerbations, either of the mind or of the 
passions, as well as over exertion and fatigue of the body; for 
they involve an expenditure of the vital forces, which you will 
need when you come to struggle in the throes of this terrible 
malady, and without which you can scarcely hope to recover. 

And if, in spite of these precautions, it should be your lot to be 
prostrated by this scourge of our race, be assured that you will 
not regret having lived a sober and virtuous life. 

COMPILES. 



121 

GLOSSARY. 



ABSORBENTS. — Minute vessels which take up nutritive matters from the 

alimentary canal and convey them into the circulation. "^ 

AERATE. — The change which takes place in the Mood on its passage through 

the lungs. ^ 

ALBUMEN'. — A thick, glairy fluid, as white of egg. 
ALBUMENOID. — Having the properties of albumen. 

' JBTIOLOGY. — The doctrine of the cause of disease. „>■ 

ALGIDE. — Cold ; applied to the cold stages of cholera, and fevers. 
ALIMENT.— Food. 
ALIMENTARY CANAL.— The tube or canal through the body, from the 

mouth to the fundament. 
ALKALINE. — Having the property of neutralizing acids. 
ALKALOID. — Having the properties of an alkali. 

ALVINE. — Belonging to the abdomen. ^ 

ANASARCA.- Cellular dropsy. 
ANUS. — Lower termination of the bowel. 
AORTA. — The main artery leading from the heart. 
A PRIORI. — From cause to effect. 

ARACHNOID. — The serous membrane covering the brain and spinal cord. 
AREOLAR.— The cellular and connective tissue between different organs and 

textures. *»"• 

ARTERIALIZE.— See aerate. 

ASCITIS.— Dropsy of the belly. v 

ASPHYXIA.— Spasm of the lungs. 
AURICLE. — One of the chambers of the heart. 
AUTOPSY. — Inspection after death. 
BACTERIA. — Microscopic animalculse, 
BRONCHIA.— Air tubes of the lungs. 

BUCCAL. — Pertaining to the mucous membrane lining the mouth. 
BORBORYGMUS.— Rumbling noise in the bowels. 
CETERIS PARIB US.— Other things being equal. 
CALORIC— Heat. 
CAPILLARY. — Resembling hairs in size ; minute vessels which permeate 

the tissue. 
OARBOLIC ACID.— An acid product of coal. 
CARDIAC. — Pertaining to the heart. 
CATALYTIC. — The power of one body to produce change in another body 

by contact. 
CELL,-^- A minute closed vesicle ; primary form of organized matter. 



122 

CHLOROF. —Chloroform. 

CELLULAR.— See areolar. 

CEREBRAL.— Pertaining to the brain. 

CHOLAGOGUE.— That which promotes the flow of bile. 

CILIA. — Microscopic hairs. 

COLLAPSE — To sink down from failure of the vital functions. 

COAGULA. — Clots, partly solidified in a fluid, as the blood. 

CGECUM. — A kind of sack at the commencement of the large bowel. 

CORDONS SANIT AIRES.— Guards against the spread of pestilence, 

COLON.— The large bowel. 

CONCENT —Concentrated. 

COLUMNAR. — Formed in columus. 

CREPITANT.— Making a crackling noise. 

CUTICLE.— The external layer of the skin. 

CONSISTENT.— Degree of density. 

CONVALESENCE.— Returning to health. 

DEBRIS.— Cast off; waste matter. 

DENUDE. — To deprive of the outer covering. 

DEPERDITION.— To fail to reach maturity; abortion. 

DISINFECT.— To deprive of the power to infect. 

DISINFECTANT.— That which disinfects. 

DORSAL. — Pertaining to the back. 

DETRITUS.— Earthy matter. 

DIPHTHERIA. — A disease in which there is a tendency to membraneous 

exudation.. 
DUODENUM.— First division of the bowel below the stomach. 
DYSPNCE A.— Difficulty of breathing. 
EFFETE.— Worn out. 
ELIMINATE.— To throw out or separate. 
EMPHYSEMA. — Accumulations of air in the cellular tissue. 
ENDEMIC. — Being confined to a particular locality. 
ENDER MIC— Under the skin. 

EPIDEMIC— Spreading over many districts or countries. 
EPIDEMIOLOGY.— Science of epidemics. 
EPIDERMIC- Pertaining to the outer skin. 
EPITHELIUM. — A thin covering of the mucous membrane. 
EPITHELIAL. — Pertaining to the epithelium, as columnar, tessellated and 

ciliated epithelial cells. 
ERE M AC AUSIS.— Decay. 
ETIOLOGY.— Cans 3 of disease. 
EXASCERBATION.— Exasperation, excitement. 
EXANTHEMATA.— Eruptive diseases. 
EXCRETA.— That which is thrown out or separated by secretion. 






128 ■ 

EXCREMENT.— Discharges from the bowels. 

EXCRETORY. — Pertaining to the organs of excretion. — "■ 

EXFOLIATE.— To peel off or cast off. „ ^ 

EXOSMOSIS. — To exude out through an animal membrane, 

FAHR. — Fahrenheit, thermometer in common use in the Uhited States* 1 . 

FERRI SULPH.— Sulphate of iron ; copperas. 

FLOCCULI — Locks or fleeces. 

F03CES.— Matters discharged from the bowels. 

FOETOR.— Disagreeable odor. 

FOLLICLE.— A little bag or cyst ; a gland. 

FUNGOID — Resembling fungus. 

FUNGUS.— A mushroom. 

FUNGI.— Plural of fungus. 

FORMULA.— A prescribed form. 

GANGLION. — A collection of nerve fibres and nerve cells. 

GANGRENE.— First stage of mortification. 

GASTRIC. — Pertaining to the stomach. 

G ASTRO-INTESTINAL.— Pertaining to the stomach and bowels. 

GENESIS. — Origin or source of origin. _, :J 

GERM. — Seed or reproductive principle. 

GERMINAL.— Pertaining to germ. 

GLANDS. — All the secreting organs of the body are so called. 

GLANDS OF BR UNNER— Small granular bodies situated in the duodenum. 

GLANDS OF PEYER.— Clusters of minute granular bodies situated in the 

small intestines. 
GRAMMA. — A measure of about 15£ grains, Troy. 
ELEMATEMESIS.— Vomiting of blood. 

HAEMORRHAGE.— Spontaneous bleeding. ^ 

HEPATIZE. — To become like the substance of the liver. 
HERNIA. — Rupture ; a protrusion of the bowel through the walls of the 

abdomen. 
HOMOGENEOUS.— Having the same nature. 
HYDRATING. — Compounding a metallic oxide with water. 
HYGIENE.— Rules for preserving health. 
HYPEREMIA.— An excess of blood. 
HYPERTROPHY.— Excessive growth of a part. 
HYPODERMIC— Under the skin. 
HYPOSTATIC — Relating to stagnation of the fluids, or sediments and; 

deposits. 
IDIOSNYCR AS Y.— Individual peculiarity. ,^' 

ILEO C(ECAL YALVE. — Situated at the junction of the ileum and coecum. 
ILEUM. — The lower division of the small intestine or bowel. 
INFECTION.— Matters or effluvia which produce disease. 



124 

INFILTRATE.— To infuse fluids into the tissues. 
INFUSORLE. — Microscopic insects inhabiting water. 
INGEST A. — Matters taken into the stomach as food. 
IN LIMINE.— At the threshold. 
INNERVATION. — A condition of nervous power. 

INTESTINES. — That portion of the alimentary canal below the stomach. 
INTERCRANIAL.— "Within the cranium or skull. 
IRRITATION. — Unusual excitement of a part or organ. 
•JACTITATION. — Restlessness or nervous twitching. 
JEJUNUM. — First division of the small intestines or bowels. 
LAZARETTO.— A hospital for infected persons. 
LESION. — Any alteration of the healthy structure of the tissues by injury or 

disease. 
LIQ. FERRI OXY. SULPHATIS —Hyper oxidated sulphate of iron. 
LITRE. — A liquid measure of 16 ounces. 
LIQ. SANGUINIS.— The fluid portion of the blood. 
LYMPH. — A colorless animal secretion. 

MALARIA. — Poisonous emanations from unhealthy soils and waters. 
MATERIES MORBI. — Morbid materials ; agents which cause disease 
MEDULA OBLONGATA.— The portion of the spinal marrow next to the 

brain. 
MESENTARY. — The membrane which connects the small intestines with 

the posterior wall of the abdomen. 
MITRAL VALVES.— Yalves which guard the left auricle of the heart. 
MODUS OPERANDI.— The mode of operation. 
MUCIPAROUS.— Producing mucous. 
NASAL. — Belonging to the nose. 

NUCLEI. — A small speck of germ matter ; center of a blood celL 
NUTRIENT. — Having nourishing properties. 
NITROGENOUS.— Having the properties of nitrogen. 
NOSOLOGY. — Classification of diseases. 
ORGANISM,— A system of organs. 

OSMOSIS. — Passage of a fluid through animal membranes. 
OZONE. — A gaseous fluid supposed to be allied to oxygen. 
PABULUM.— Food ; nutriment. 
PANCREAS. — A glandular structure below the stomach which secretes a 

peculiar digestive fluid. 
PAPILLAE. — Small elevations on the mucous membranes, as seen on the 

upper surface of the tongue. 
PARASITE. — A plant or animal that grows upon or in another plant or 

animal. 
PARENCHYMA. — Applied to a pulpy substance in the tissues 
PATHOGNOMIC. — A symptom which distinguishes a disease. 






■■ 






125 -* 

P\ATEtOLOGY. — Disease, or a treatise on disease. 

PELVIS. — The bony structure forming the lower part of the abdomen. 

PERITONEUM.— The serous membrane covering the inner walls of th© ^ 

abdomen and intestines. 
PLEXUS.^A complex network of nerves and capillaries. 
PORTAL SYSTEM.— The system of veins which convey the bloood through 

the liver. 
PLASMA.— The nutritive matters of the blood. <** 

PR^E CORDIAL.— The front region of the chest. 
PREMONITORY.— The first indications of disease. 
PRIMES VIM.-^ Alimentary canal. 
PROPHYLATIC.— A preventive of disease. 

PROTOZOA. — Insects having only the simplest forms of organization. 
PYEMIA.— Pus or matter in the blood. 
PEYER'S GLANDS.— See glands. 

RECTUM. — The lower division of the bowel terminating at the anus. 
RIGOR MORTIS.— Rigidity of death. 
SAL VOLATILE.— A salt of ammonia. 

SATURNINE.— Lead poison ; sadness. ^ 

SEMILUNAR YALYES.— Situated at the orifice of the pulmonary arteries. 
SEMILUNAR G-ANG-LIONS.— Small nerve centers situated in the abdomen. 
SEQUILiE. — Following a prior event. 
SEROSITY. — Having the properties of serum. 
SERUM. —The watery portion of the blood. 
SINUSES.— Cavities. 

SPAN^MlA.— Excess of water in the blood. 
SPINAL NERVES. — Nerves originating in the spine. 
SPLEEN. — A large blood gland situated at the left lower margin of the A 

stomach. 
SOLITARY GLANDS.— See gland of Brunner. 
SQUAMOUS — Having the appearance of scales ; scaley. 
SPIR. VINT.— Spirits of wine. 
STEARINE.- Fat. 

STRANGULATED.— Being constricted or tied. 
SUBARACHNOID. — One of the membranes covering the brain. 
SUBCLAVIAN. — Under the clavicle or collar bone. 
SUBCUTANEOUS.— Under the skin. 
SULPHATE OF IRON.— Copperas. 
SYNCOPE.— Fainting. 

SYSTEMIC— Belonging to the general circulation. 
TICT. FERRI MUR.— Muriated tincture of iron. 
TERGAL.— See dorsal. 
TOXIC. —Pertaining to poisons. 



126 

TOXEMIA.— Poisoning of the blood. 

TR^ECHIA.— The windpipe. 

TRACHEOTOMY.— Operation for opening the windpipe". 

TRANSFUSION,— Passing the blood of one individual into the veins ol 

. another. 
TISSUES. — Various parts of which an organ is composed. 
TUBES OF PERREIN.— Uriniferoils tubes of the kidneys. 
UBI IRRITATIO IBI FLUXES.— Where the irritation is there will be a 

flux or congestion of the blood. 
UREA. — A substance found in the urine. 
URIC ACID.— An acid of which urea is the base. 
UVULA. — The fleshy appendage of the soft palate. 

Variola.— The smaii-pox. 

VASCULAR, — Pertaining to the blood-vessels. 

VENA PORT^E.— The vein which carries the blood through the liver. 

VENA OZYGOS.— A vein of the thorax or chest. 

VESICLE. — A minute blister or bladder containing transparent fluid. 

VESICULAR. —Having the form of a vesicle. 

VENTRICLES.— Two of the chambers of the heart. 

VILLI. — Applied to the hairy coating of the mucous lining of the bowels* 

VIS A TER GO. —Applied to vital force, as that of the heart. 

VlBRIONES. — A species of animalculae. 

VISCID.— Tough ; ropey. 

ZYMOTIC. — Being caused by malarious poison or effluvia. 

g ; ounce; g ? drachm; gr., grain. 



ADDENDITN. 

tJHYLE.— A milky fluid, produced by digestion, in the small intestines. 
CIRRHOSIS.— A disease of the liver, which hardens its textures and desta»t 

its functions. 
POSES MOLULT.— Vessels for secreting night soils. 
NORMAL.— Natural— healthy. 
PHARYNX.— The space between the back part of the mouth and the 'appetf 

end of the windpipe. 
PHYSIOLOGY.— The science of health. 
PYLORUS.— The lower orifice of the stomach. 

THORACIC DUCT.— A vessel which conveys chyle and lymph into the! 
blood, 



INDEX OF AUTHORS, 



PAGE* 
ALTHATJS, DR. JULIUS— On the nature of the supposed cholera 

poison . 19* 

BE ALE, DR. L. S. — Microscopic researches on cholera 30 

BOWEEBANK, DE.— On quarantine in cholera 96 

BOWEEBANK, DE. — On the treatment of premonitory diarrhoea and 

cholera . , 107 

CHEYEES, DE. NOBMAN— On the influence of impure water .„. 14 

CLAEKE, DE. A. — On the use of warm haths in cholera 116 

COMPILER— Concluding remarks 118 

COOPEE, SIR HENRY— On the relations hetween diarrhoea and 

cholera 105 

FARE, DE. W.— Extract from an address by & 

GLOSSAEY 121 

GOODEVE, DE. E.— On the International Sanitary Conference 55 

GUISINGEE, PETTENKOFEB AND WUNDEBLICH, DES.-On 

rules for the guidance of sanitary authorities and practitioners 71 

JENNEE, FAER, MILBOY, DES.— On same . 65 

JOHNSON, DE. GEOEGE— On rules for the treatment of cholera 98 

MacCOEMAC, DE. HENEY— On the prophylactic arrest of cholera.... 105' 

MACLEAN, DE. — On the treatment of premonitory diarrhoea and 

cholera 10$ 

McCLOY, DE. — On Eubini's treatment of cholera < 117 

MEDICAL NEWS AND LIBRARY— On Dr. Johnson's illuminative 

treatment.. * 103 

MEDICAL NEWS AND LIBRARY— On the pathology of cholera, 

A review of .... 38' 

NEW YORK ACADEMY OP MEDICINE— On the preventive and 

remedial treatment of cholera. 94 

PETTENKOFER, DR. MAX— On disinfection 67 

QUARANTINE AND CHOLERA— Lancet 95 

RICHARDSON, DE. B. W.— On Snow's theory of the causes of cholera W 

RICHARDSON, DR. B. W.— On the origin, cause and prevention of 

cholera.... 26 

RUBINI, DR. — On camphor in the treatment of cholera 117 

SIMON, ME. JOHN — On the mode of propagation of cholera............... 17 






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